MEDICARE: MGC PHARMACY LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PH22923	OTHER	FL	PHARMACY

General Provider Information

NPI Number	:	1700076262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MGC PHARMACY LLC

Provider Business Mailing Address
First Line	:	1516 E 4TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-3159
Country	:	US
Telephone Number	:	305-586-6443
Fax Number	:	305-884-7454

Provider Business Practice Location Address
First Line	:	1516 E 4TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-3159
Country	:	US
Telephone Number	:	305-586-6443
Fax Number	:	305-884-7454

Authorized Official
Title or Position	:	PHARMACY OWNER/ MANAGER ON RECORD
Name	:	DR. LUIS ALFONSO-SERRANO
Credential	:	PHARMD MSC
Telephone Number	:	305-586-6443

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	11/10/2010

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