Provider Demographics
NPI:1447521166
Name:GUTIERREZ, EDWARD CERECEDA
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CERECEDA
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 MONTAGUE CT E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-1217
Mailing Address - Country:US
Mailing Address - Phone:727-772-9089
Mailing Address - Fax:
Practice Address - Street 1:1477 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6243
Practice Address - Country:US
Practice Address - Phone:727-733-3176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist