=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639323777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVEN ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2008
-----------------------------------------------------
Last Update Date | 11/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 6TH ST SE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-294-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 6TH ST SE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-294-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MABEL R GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-294-1400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 23713
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------