MEDICARE: EXCELLENCE PHARMACY DISCOUNT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PH26678	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2140091	OTHER		PK

General Provider Information

NPI Number	:	1356619209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELLENCE PHARMACY DISCOUNT INC

Provider Business Mailing Address
First Line	:	12887 SW 42ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-3435
Country	:	US
Telephone Number	:	305-846-9243
Fax Number	:	305-967-8744

Provider Business Practice Location Address
First Line	:	12887 SW 42ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-3435
Country	:	US
Telephone Number	:	305-846-9243
Fax Number	:	305-967-8744

Authorized Official
Title or Position	:	OWNER
Name	:	SIMON PALACIO
Credential	:
Telephone Number	:	305-846-9243

Provider Enumeration Date	:	12/07/2011
Last Update Date	:	04/26/2013

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