=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699810663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMA CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2629 DAVIE BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-583-9433
-----------------------------------------------------
Fax | 954-587-7863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2629 DAVIE BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-583-9433
-----------------------------------------------------
Fax | 954-587-7863
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STORE MANAGER
-----------------------------------------------------
Name | JANIUS GOMEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-583-9433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH252
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------