Healthcare Provider Details

I. General information

NPI: 1265766745
Provider Name (Legal Business Name): MONIQUE ALEXIS GRANT-SUPPLICE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST PHARMACY SERVICE (119)
MIAMI FL
33125-1624
US

IV. Provider business mailing address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-7000
  • Fax:
Mailing address:
  • Phone: 305-575-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPS44024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: