=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275958274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAC SHORES PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 07/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9416 NE 2ND AVE
-----------------------------------------------------
City | MIAMI SHORES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33138-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-313-3018
-----------------------------------------------------
Fax | 786-334-5659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9416 NE 2ND AVE
-----------------------------------------------------
City | MIAMI SHORES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33138-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-313-3018
-----------------------------------------------------
Fax | 786-334-5659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | SAPNA CHARANIA
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 786-313-3018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH27571
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------