1174840581 NPI number — PALM PHARMACY

Table of content: (NPI 1174840581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174840581 NPI number — PALM PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM PHARMACY
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:
PALM PHARMACY
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:
1174840581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
486 PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIALEAH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33010-4718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-392-0051
Provider Business Mailing Address Fax Number:
305-392-0052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
486 PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33010-4718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-392-0051
Provider Business Practice Location Address Fax Number:
305-392-0052
Provider Enumeration Date:
04/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CALERA
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
786-262-3007

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH24542 , 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: 5700035 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".