MEDICARE: PREMIUM 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	PH23505	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1036854	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578728895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM PHARMACY INC

Provider Business Mailing Address
First Line	:	8901 SW 157TH AVE
Second Line	:	STE 3
City	:	MIAMI
State	:	FL
Zip	:	33196-1102
Country	:	US
Telephone Number	:	305-385-2900
Fax Number	:	305-385-2999

Provider Business Practice Location Address
First Line	:	8901 SW 157TH AVE
Second Line	:	STE 3
City	:	MIAMI
State	:	FL
Zip	:	33196-1102
Country	:	US
Telephone Number	:	305-385-2900
Fax Number	:	305-385-2999

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. YUDITH FERNANDEZ
Credential	:
Telephone Number	:	305-385-2900

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	10/07/2011

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Directions to “PREMIUM PHARMACY INC ” Practice Location

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