Healthcare Provider Details

I. General information

NPI: 1700146461
Provider Name (Legal Business Name): MY HEALTH SOUTH PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11948 MIRAMAR PARKWAY
MIRAMAR FL
33025
US

IV. Provider business mailing address

11948 MIRAMAR PARKWAY
MIRAMAR FL
33025
US

V. Phone/Fax

Practice location:
  • Phone: 954-703-1069
  • Fax: 888-461-4991
Mailing address:
  • Phone: 954-703-1069
  • Fax: 888-461-4991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH26156
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH26155
License Number StateFL

VIII. Authorized Official

Name: DENNIS BONNEAU
Title or Position: PRESIDENT
Credential:
Phone: 954-703-1069