=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720164841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILAGROS PHARMACY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 01/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 SW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33130-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-541-0094
-----------------------------------------------------
Fax | 305-541-0717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 SW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33130-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-541-0094
-----------------------------------------------------
Fax | 305-541-0717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALDO LEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-541-0094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH17258
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------