1306310545 NPI number — CANO PHARMACY, LLC

Table of content: (NPI 1306310545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306310545 NPI number — CANO PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANO PHARMACY, 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:
1306310545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/12/2024
NPI Reactivation Date:
12/16/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9725 NW 117TH AVE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33178-1212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-432-0578
Provider Business Mailing Address Fax Number:
954-432-5060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5190 NW 167TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33014-6329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-870-1170
Provider Business Practice Location Address Fax Number:
786-870-1133
Provider Enumeration Date:
01/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
DEMARQUETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
754-300-9039

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105099700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com