=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700146461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY HEALTH SOUTH PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2012
-----------------------------------------------------
Last Update Date | 08/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11948 MIRAMAR PARKWAY
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-703-1069
-----------------------------------------------------
Fax | 888-461-4991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11948 MIRAMAR PARKWAY
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-703-1069
-----------------------------------------------------
Fax | 888-461-4991
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DENNIS BONNEAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-703-1069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number | PH26155
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH26156
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------