Healthcare Provider Details

I. General information

NPI: 1619424512
Provider Name (Legal Business Name): EZ RX HALLANDALE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 W 84TH ST #62
HIALEAH FL
33014-3379
US

IV. Provider business mailing address

1550 W 84TH ST #62
HIALEAH FL
33014-3379
US

V. Phone/Fax

Practice location:
  • Phone: 786-703-5670
  • Fax: 786-703-5657
Mailing address:
  • Phone: 786-703-5670
  • Fax: 786-703-5657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH30285
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MIRTHA GONZALEZ
Title or Position: OWNER
Credential:
Phone: 786-703-5670