MEDICARE: CHARLIES DRUG STORE 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

General Provider Information

NPI Number	:	1376951061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLIES DRUG STORE INC

Provider Business Mailing Address
First Line	:	2350 W 84TH ST
Second Line	:	BAY 15
City	:	HIALEAH
State	:	FL
Zip	:	33016-5575
Country	:	US
Telephone Number	:	786-534-3997
Fax Number	:	786-534-3998

Provider Business Practice Location Address
First Line	:	2350 W 84TH ST
Second Line	:	BAY 15
City	:	HIALEAH
State	:	FL
Zip	:	33016-5575
Country	:	US
Telephone Number	:	786-534-3997
Fax Number	:	786-534-3998

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARLOS FONSECA
Credential	:
Telephone Number	:	786-534-3997

Provider Enumeration Date	:	07/26/2014
Last Update Date	:	07/26/2014

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Directions to “CHARLIES DRUG STORE INC ” Practice Location

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