Healthcare Provider Details

I. General information

NPI: 1538104740
Provider Name (Legal Business Name): BRANCH ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17490 SW 104TH AVE STE B
MIAMI FL
33157-4200
US

IV. Provider business mailing address

17490 SW 104TH AVE STE B
MIAMI FL
33157-4200
US

V. Phone/Fax

Practice location:
  • Phone: 305-969-3353
  • Fax: 305-969-3115
Mailing address:
  • Phone: 305-969-3353
  • Fax: 305-969-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH18244
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EVANS BRANCH III
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 305-969-3353