=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003098971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | #1 RX LIBERTY PHARMACY DISCOUNT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2007
-----------------------------------------------------
Last Update Date | 05/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 972 E 25TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33013-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-691-6686
-----------------------------------------------------
Fax | 305-691-6682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 972 E 25TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33013-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-691-6686
-----------------------------------------------------
Fax | 305-691-6682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PEDRO PABLO ROSADO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-691-6686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------