=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871895847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY DEPOT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2010
-----------------------------------------------------
Last Update Date | 11/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1304A E ATLANTIC BLVD
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-6745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-650-0823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1304A E ATLANTIC BLVD
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33060-6745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-650-0823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | CHRISTIAN LEO SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-650-0823
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PH24969
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------