MEDICARE: SOUTHERN STATES PHARMACY

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	PH24848	FL

General Provider Information

NPI Number	:	1437466968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN STATES PHARMACY

Provider Business Mailing Address
First Line	:	4047 OKEECHOBEE BLVD
Second Line	:	SUITE #120
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4047 OKEECHOBEE BLVD
Second Line	:	SUITE #120
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3239
Country	:	US
Telephone Number	:	561-487-3808
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OMAR ONESTA HARVEY
Credential	:
Telephone Number	:	561-487-3808

Provider Enumeration Date	:	09/03/2010
Last Update Date	:	09/03/2010

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Directions to “SOUTHERN STATES PHARMACY ” Practice Location

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