=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861023822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. STANLEY JEAN CHARLES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2020
-----------------------------------------------------
Last Update Date | 01/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8323 NW 12TH ST STE 108
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-374-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8323 NW 12TH ST STE 108
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-374-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS59834
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------