MEDICARE: COUNTRY CLUB PHARMACY AND 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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37199	OTHER	FL	DOCUMENT NUMBER

General Provider Information

NPI Number	:	1356641559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY CLUB PHARMACY AND DISCOUNT INC

Provider Business Mailing Address
First Line	:	5911 NW 173RD DR
Second Line	:	# 6
City	:	HIALEAH
State	:	FL
Zip	:	33015-5121
Country	:	US
Telephone Number	:	305-828-8600
Fax Number	:	305-828-8630

Provider Business Practice Location Address
First Line	:	5911 NW 173RD DR
Second Line	:	# 6
City	:	HIALEAH
State	:	FL
Zip	:	33015-5121
Country	:	US
Telephone Number	:	305-828-8600
Fax Number	:	305-828-8630

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAISY MARTINEZ
Credential	:
Telephone Number	:	305-828-8600

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	10/22/2010

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