=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235560301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH POINT PHARMACY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2013
-----------------------------------------------------
Last Update Date | 12/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1864 W FLAGLER ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33135-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-541-8699
-----------------------------------------------------
Fax | 305-541-8696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1864 W FLAGLER ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33135-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-541-8699
-----------------------------------------------------
Fax | 305-541-8696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NELSON SUAREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-288-1467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH25797
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------