MEDICARE: WEST PALM 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
2	3336C0003X	Community/Retail Pharmacy	PH25847	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5708485	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1619246378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PALM PHARMACY LLC

Provider Business Mailing Address
First Line	:	5760 OKEECHOBEE BLVD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-4343
Country	:	US
Telephone Number	:	561-249-2130
Fax Number	:	561-249-2104

Provider Business Practice Location Address
First Line	:	5760 OKEECHOBEE BLVD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33417-4343
Country	:	US
Telephone Number	:	561-249-2130
Fax Number	:	561-249-2104

Authorized Official
Title or Position	:	PHARMACIST/OWNER
Name	:	SALIM SOUFAN
Credential	:	RPH
Telephone Number	:	561-249-2130

Provider Enumeration Date	:	12/23/2011
Last Update Date	:	11/29/2012

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Directions to “WEST PALM PHARMACY LLC ” Practice Location

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