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General NPI Number Information
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NPI Number | 1215789946
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Entity Type | Organization
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Legal Business Name | PHARMACY AT 100 NW 170TH ST, LLC
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Dates
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Enumeration Date | 04/04/2024
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Last Update Date | 04/04/2024
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Provider Practice Location Address
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Address Line | 15485 EAGLE NEST LN STE 230
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City | MIAMI LAKES
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State | FL
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Zip | 33014-2222
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Country | US
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Telephone | 917-440-1529
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Fax |
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Provider Business Mailing Address
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Address Line | 15485 EAGLE NEST LN STE 230
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City | MIAMI LAKES
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State | FL
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Zip | 33014-2222
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Country | US
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Telephone | 917-440-1529
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RICHARD RAY
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Credential |
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Telephone | 917-440-1529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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