1326045345 NPI number — THE MEDICARE SHOPPE INCORPORATED

Table of content: (NPI 1326045345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326045345 NPI number — THE MEDICARE SHOPPE INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MEDICARE SHOPPE INCORPORATED
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:
1326045345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3013 E 4TH 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:
33013-3210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-693-3544
Provider Business Mailing Address Fax Number:
305-693-3519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3013 E 4TH 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:
33013-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-693-3544
Provider Business Practice Location Address Fax Number:
305-693-3519
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDEZ
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
ANDRES
Authorized Official Title or Position:
PRESIDENT / PROGRAM DIRECTOR
Authorized Official Telephone Number:
305-693-3544

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1222810001 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: PH16014 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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