Provider Demographics
NPI:1881295319
Name:WRIGHTMAN, MARK CHRISTOPHER
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:WRIGHTMAN
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 1:1220 GARRISON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1075
Mailing Address - Country:US
Mailing Address - Phone:904-305-4715
Mailing Address - Fax:
Practice Address - Street 1:10251 SHOPS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7406
Practice Address - Country:US
Practice Address - Phone:904-288-8189
Practice Address - Fax:904-288-8450
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist