=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932356409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACOBS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2008
-----------------------------------------------------
Last Update Date | 04/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 261 WESTWARD DR SUITE 115-116
-----------------------------------------------------
City | MIAMI SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-953-5643
-----------------------------------------------------
Fax | 786-953-5644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 261 WESTWARD DR SUITE 115 -116
-----------------------------------------------------
City | MIAMI SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-5290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-953-5643
-----------------------------------------------------
Fax | 786-953-5644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADA ALBERTO GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-953-5643
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH23544
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------