MEDICARE: GAVIOTA PHARMACY DISCOUNT CORP

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	PH23661	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1041475	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1467605733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAVIOTA PHARMACY DISCOUNT CORP

Provider Business Mailing Address
First Line	:	10521 SW 40TTH STREET
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3747
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10521 SW 40TTH STREET
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3747
Country	:	US
Telephone Number	:	305-223-6469
Fax Number	:	305-223-6479

Authorized Official
Title or Position	:	OWNER
Name	:	ODALYS SANTANA
Credential	:
Telephone Number	:	305-223-6469

Provider Enumeration Date	:	10/29/2008
Last Update Date	:	03/16/2009

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