MEDICARE: MOHAMED SALEH DISPENSARY

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	332900000X	Non-Pharmacy Dispensing Site	ME43827	FL

General Provider Information

NPI Number	:	1518130590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOHAMED SALEH DISPENSARY

Provider Business Mailing Address
First Line	:	2301 W SAMPLE RD
Second Line	:	SUITE 7A
City	:	POMPANO BEACH
State	:	FL
Zip	:	33073-3081
Country	:	US
Telephone Number	:	954-935-6063
Fax Number	:	954-935-0470

Provider Business Practice Location Address
First Line	:	1408 SAN MARCO BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8536
Country	:	US
Telephone Number	:	904-398-0009
Fax Number	:	904-346-0887

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR
Name	:	MS. CICELY EASON
Credential	:
Telephone Number	:	954-935-6063

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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