MEDICARE: SOLANTIC OF SOUTH FL, 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	HCC 6190	FL

General Provider Information

NPI Number	:	1538483029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLANTIC OF SOUTH FL, LLC

Provider Business Mailing Address
First Line	:	8711 PERIMETER PARK BLVD
Second Line	:	SUITE 6
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6388
Country	:	US
Telephone Number	:	904-223-2330
Fax Number	:	904-425-4356

Provider Business Practice Location Address
First Line	:	9035 PINES BLVD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-6440
Country	:	US
Telephone Number	:	954-378-0333
Fax Number	:	954-378-0330

Authorized Official
Title or Position	:	CEO
Name	:	KAREN BOWLING
Credential	:
Telephone Number	:	904-223-2330

Provider Enumeration Date	:	03/26/2010
Last Update Date	:	03/26/2010

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