MEDICARE: PALM LAKES PHARMACY, INC.

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	3336C0003X	Community/Retail Pharmacy	APPLIED FOR	FL

General Provider Information

NPI Number	:	1285793828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM LAKES PHARMACY, INC.

Provider Business Mailing Address
First Line	:	3300 W 84TH ST
Second Line	:	BAY #3
City	:	HIALEAH
State	:	FL
Zip	:	33018-4903
Country	:	US
Telephone Number	:	305-823-2885
Fax Number	:	305-823-2890

Provider Business Practice Location Address
First Line	:	3300 W 84TH ST
Second Line	:	BAY #3
City	:	HIALEAH
State	:	FL
Zip	:	33018-4903
Country	:	US
Telephone Number	:	305-823-2885
Fax Number	:	305-823-2890

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ROSALIA DEYSI PEREZ
Credential	:
Telephone Number	:	305-823-2885

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	11/05/2008

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