License Number: MM34310Data As Of 5/26/2017
|License Expiration Date||8/31/2017|
|License Original Issue Date||10/14/2015|
|Address of Record||5915 5915 4TH STREET NORTH|
|SAINT PETERSBURG, FL 33702|
|Controlled Substance Prescriber||No|
|Discipline on File||No|
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