MEDICARE: IVONNE LAGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS45639	FL

General Provider Information

NPI Number	:	1033714860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVONNE LAGE

Provider Business Mailing Address
First Line	:	4410 W 16TH AVE STE 9
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-7101
Country	:	US
Telephone Number	:	786-353-0085
Fax Number	:	305-490-6394

Provider Business Practice Location Address
First Line	:	4410 W 16TH AVE STE 9
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-7101
Country	:	US
Telephone Number	:	786-353-0085
Fax Number	:	305-490-6394

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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Directions to “ IVONNE LAGE ” Practice Location

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