MEDICARE: MED-LAB COMPOUNDING

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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy	PH28330	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2147240	OTHER		PK

General Provider Information

NPI Number	:	1538568803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED-LAB COMPOUNDING

Provider Business Mailing Address
First Line	:	9963 SW 142 AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186
Country	:	US
Telephone Number	:	786-534-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	9963 SW 142ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-6844
Country	:	US
Telephone Number	:	786-534-7533
Fax Number	:

Authorized Official
Title or Position	:	TECHNICIAN
Name	:	NEREYDA ROJAS
Credential	:
Telephone Number	:	786-534-7533

Provider Enumeration Date	:	08/22/2014
Last Update Date	:	11/20/2014

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Directions to “MED-LAB COMPOUNDING ” Practice Location

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