=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992865158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILES S JUDAH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 457 CARLTON STREET
-----------------------------------------------------
City | WAUCHULA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33873-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-773-4525
-----------------------------------------------------
Fax | 863-773-2842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 457 CARLTON STREET
-----------------------------------------------------
City | WAUCHULA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33873-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-773-4525
-----------------------------------------------------
Fax | 863-773-2842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHARMACIST
-----------------------------------------------------
Name | MR. MILES S JUDAH
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 863-773-4525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH6314
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------