=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790088805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR FRIENDLY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2010
-----------------------------------------------------
Last Update Date | 03/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 458 W HILLSBORO BLVD 458 B
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-420-5273
-----------------------------------------------------
Fax | 954-420-5276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 458 W HILLSBORO BLVD 458 B
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-420-5273
-----------------------------------------------------
Fax | 954-420-5276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | LANA WISEBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-420-5273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 24627
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------