1497828065 NPI number — PANACEA INC

Table of content: (NPI 1497828065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497828065 NPI number — PANACEA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PANACEA 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:
MEDICAL ARTS 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:
1497828065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
944 N KROME AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMESTEAD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-247-4488
Provider Business Mailing Address Fax Number:
305-248-8375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
944 N KROEM AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-247-4488
Provider Business Practice Location Address Fax Number:
305-248-8375
Provider Enumeration Date:
11/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CONDO
Authorized Official First Name:
MUHIZI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-247-4488

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PH471 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH471 , 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: 104850300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH471 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 113650500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".