=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477652428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIAN RIVER MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 36TH ST RETAIL PHARMACY
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-4862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-567-4311
-----------------------------------------------------
Fax | 772-794-1462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 36TH ST RETAIL PHARMACY
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-4862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-567-4311
-----------------------------------------------------
Fax | 772-794-1462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O. PRESIDENT
-----------------------------------------------------
Name | MR. JEFFERY SUSI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-567-4311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH-8926
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------