=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023382512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEED II PHAMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2012
-----------------------------------------------------
Last Update Date | 11/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 W 12TH AVE STE 4
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-310-7845
-----------------------------------------------------
Fax | 786-310-7851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 W 12TH AVE STE 4
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-310-7845
-----------------------------------------------------
Fax | 786-310-7851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GUIDO DE LA TORRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-325-2551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH26049
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------