=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720477292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 955 WASHINGTON HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2015
-----------------------------------------------------
Last Update Date | 01/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 WASHINGTON AVE
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-531-1256
-----------------------------------------------------
Fax | 305-531-0562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 WASHINGTON AVE
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-531-1256
-----------------------------------------------------
Fax | 305-531-0562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER PARTNER
-----------------------------------------------------
Name | MICHAEL CORBIN
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 305-531-1256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH28526
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------