1063423606 NPI number — COMMCARE PHARMACY MIA LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063423606 NPI number — COMMCARE PHARMACY MIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMCARE PHARMACY MIA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063423606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
855 SW 78TH AVE
Provider Second Line Business Mailing Address:
STE C100
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-568-6212
Provider Business Mailing Address Fax Number:
954-568-2765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 CORAL WAY
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33145-2790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-854-5535
Provider Business Practice Location Address Fax Number:
305-854-5929
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGHERTY
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
954-332-6170

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH21974 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 031649100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2006806 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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