=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730298563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERSEN INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 02/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2666 SW 87TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-229-1300
-----------------------------------------------------
Fax | 305-229-1532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2666 SW 87TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | YAILKA FRAGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-266-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH0015272
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------