Healthcare Provider Details

I. General information

NPI: 1568662625
Provider Name (Legal Business Name): IDEAL RX PHARMACY JACKSON NORTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16800 NW 2ND AVE STE 100
NORTH MIAMI BEACH FL
33169-5549
US

IV. Provider business mailing address

16800 NW 2ND AVE STE 100
NORTH MIAMI BEACH FL
33169-5549
US

V. Phone/Fax

Practice location:
  • Phone: 305-493-0940
  • Fax: 305-493-0943
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH22800
License Number StateFL

VIII. Authorized Official

Name: ADRIAN DYETT
Title or Position: PRESIDENT
Credential: PHRMD
Phone: 954-864-9584