=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619246378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST PALM PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2011
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5760 OKEECHOBEE BLVD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33417-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-249-2130
-----------------------------------------------------
Fax | 561-249-2104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5760 OKEECHOBEE BLVD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33417-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-249-2130
-----------------------------------------------------
Fax | 561-249-2104
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | SALIM SOUFAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 561-249-2130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH25847
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------