Basic Information
| Provider Information | |||||||||
| NPI: | 1760478556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITEBEJAC | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | SAVA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9652 HORNE LN | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339286280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399923682 | ||||||||
| FaxNumber: | 2399923682 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 WINKLER AVENUE EXT | ||||||||
| Address2: | PHARMACY SERVICE FM VAOPC (119FM) | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
| FaxNumber: | 2399316109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS37547 | FL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.