=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962574723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUGLAS GARDENS COMMUNITY MENTAL HEALTH CENTER PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1680 MERIDIAN AVE 4TH FLOOR
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-531-5341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1680 MERIDIAN AVE SUITE 501
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-531-5341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MARY ELEANOR LANSER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 305-531-5341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PH10854
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH10854
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------