=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669882627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2014
-----------------------------------------------------
Last Update Date | 06/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4888 NW 183RD ST STE 105
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-657-3476
-----------------------------------------------------
Fax | 786-657-3280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4888 NW 183RD ST UNIT #105
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-657-3476
-----------------------------------------------------
Fax | 786-657-3280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAURICIO ALEJO SARDUY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-657-3664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH28079
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------