=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881005098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NINA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2014
-----------------------------------------------------
Last Update Date | 05/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4723 NW 79TH AVE
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-471-0091
-----------------------------------------------------
Fax | 305-471-0096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4723 NW 79TH AVE
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-471-0091
-----------------------------------------------------
Fax | 305-471-0096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANUEL SILVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-222-2655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH28125
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------