Healthcare Provider Details

I. General information

NPI: 1912145582
Provider Name (Legal Business Name): MED-SOURCE PHARMACY SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 SW 17TH AVE STE 1
MIAMI FL
33135-3878
US

IV. Provider business mailing address

515 SW 17TH AVE STE 1
MIAMI FL
33135-3878
US

V. Phone/Fax

Practice location:
  • Phone: 305-854-7377
  • Fax: 305-854-7327
Mailing address:
  • Phone: 305-854-7377
  • Fax: 305-854-7327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH 23666
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH23665
License Number StateFL

VIII. Authorized Official

Name: MR. DALLAS LONARDO
Title or Position: PRESIDENT
Credential:
Phone: 305-854-7377