Provider Demographics
NPI:1871880385
Name:MADDOX, JATEA MONET (PHARM D)
Entity type:Individual
Prefix:DR
First Name:JATEA
Middle Name:MONET
Last Name:MADDOX
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 ENTERPRISE RD
Mailing Address - Street 2:TARGET PHARMACY STORE NUMBER (T-0874)
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7960
Mailing Address - Country:US
Mailing Address - Phone:386-774-6477
Mailing Address - Fax:386-774-6477
Practice Address - Street 1:2575 ENTERPRISE RD
Practice Address - Street 2:TARGET PHARMACY STORE NUMBER (T-0874)
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7960
Practice Address - Country:US
Practice Address - Phone:386-774-6477
Practice Address - Fax:386-774-6477
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist