1063714111 NPI number — CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC

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 1063714111 NPI number — CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC
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:
CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC
Provider Other Organization Name Type Code:
3
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:
1063714111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3160 PONCE DE LEON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33134-6826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-444-5115
Provider Business Mailing Address Fax Number:
305-444-5119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3160 PONCE DE LEON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL GABLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33134-6826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-444-5115
Provider Business Practice Location Address Fax Number:
305-444-5119
Provider Enumeration Date:
11/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PAEZ
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
305-444-5115

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: 3336C0003X , with the licence number: PH25066 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5702786 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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