MEDICARE: BALDOMERO LOPEZ STATE VETERANS NURSING HOME

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	3336L0003X	Long Term Care Pharmacy	PH16499	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2012484	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700914496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALDOMERO LOPEZ STATE VETERANS NURSING HOME

Provider Business Mailing Address
First Line	:	6919 PARKWAY BLVD
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34639-2909
Country	:	US
Telephone Number	:	813-558-5000
Fax Number	:	813-558-5018

Provider Business Practice Location Address
First Line	:	6919 PARKWAY BLVD
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34639-2909
Country	:	US
Telephone Number	:	813-558-5000
Fax Number	:	813-558-5018

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	NANCY MIRANDA
Credential	:
Telephone Number	:	813-558-5000

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	06/20/2016

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