MEDICARE: OPTIMUN RX PHARMACY LLC

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	333600000X	Pharmacy	PH 28374	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2152915	OTHER		PK

General Provider Information

NPI Number	:	1518346410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUN RX PHARMACY LLC

Provider Business Mailing Address
First Line	:	6900 W 32ND AVE STE 16
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33018-5228
Country	:	US
Telephone Number	:	305-557-4995
Fax Number	:	305-557-4074

Provider Business Practice Location Address
First Line	:	6900 W 32ND AVE STE 16
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33018-5228
Country	:	US
Telephone Number	:	305-557-4995
Fax Number	:	305-557-4074

Authorized Official
Title or Position	:	OWNER
Name	:	YAMILA VAZQUEZ DE LLADO
Credential	:
Telephone Number	:	305-557-4995

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	07/02/2015

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