=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245478924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBONY DRUGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2009
-----------------------------------------------------
Last Update Date | 03/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6666 NW 15TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33147-7967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-693-8886
-----------------------------------------------------
Fax | 305-836-1657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6666 NW 15TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33147-7967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RPH
-----------------------------------------------------
Name | HERMAN HOWARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-693-8886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH23876
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------