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General NPI Number Information
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NPI Number | 1366738916
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Entity Type | Organization
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Legal Business Name | INDIAN STAR PHARM INC.
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Dates
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Enumeration Date | 06/22/2011
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Last Update Date | 12/27/2011
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Provider Practice Location Address
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Address Line | 9500 NW 79 AV BAY4
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City | HIALEAH GARDENS
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State | FL
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Zip | 33016
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Country | US
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Telephone | 786-506-6084
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Fax |
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Provider Business Mailing Address
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Address Line | 9012 NW 145TH ST
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City | HIALEAH
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State | FL
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Zip | 33018
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Country | US
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Telephone | 305-826-2170
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Fax | 305-826-2162
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARIO REYES
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Credential |
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Telephone | 786-506-6084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH25674
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License Number State | FL
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