MEDICARE: DOCTOR DIABETIC PHARMACY INC

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	PH24828	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5701417	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1659687119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTOR DIABETIC PHARMACY INC

Provider Business Mailing Address
First Line	:	100 NE 28TH STREET
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137
Country	:	US
Telephone Number	:	888-829-7581
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 NE 28TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-4423
Country	:	US
Telephone Number	:	888-829-7581
Fax Number	:	866-989-5899

Authorized Official
Title or Position	:	SR. VP PHARMACY OPERATION
Name	:	CLAYTON EDWARDS
Credential	:
Telephone Number	:	888-829-7581

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	09/03/2010

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