Provider Demographics
NPI:1548780240
Name:MATSANKA, BROOKE L (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:L
Last Name:MATSANKA
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-4127
Mailing Address - Country:US
Mailing Address - Phone:904-529-9156
Mailing Address - Fax:
Practice Address - Street 1:103 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4127
Practice Address - Country:US
Practice Address - Phone:904-529-9156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist