=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265934723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINES DISCOUNT PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2018
-----------------------------------------------------
Last Update Date | 03/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 631 NW 100TH PL
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-437-4900
-----------------------------------------------------
Fax | 954-437-4504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 NW 100TH PL
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-437-4900
-----------------------------------------------------
Fax | 954-437-4504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADEKUNLE ADIMULA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-437-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PH24151
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------