Basic Information
| Provider Information | |||||||||
| NPI: | 1588605414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLOU | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | TALLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | R. PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | 3216373684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | 3216373684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 11006 | VA | Y | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.