=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366672271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERIC RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2009
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3448 W HILLSBORO BLVD
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-9419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-420-5656
-----------------------------------------------------
Fax | 954-427-8566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3448 W HILLSBORO BLVD
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-9419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-420-5656
-----------------------------------------------------
Fax | 954-427-8566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANA IAGROSSI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-420-5656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH 24161
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------