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NPI Code Detail

MEDICARE: 1 OLD RIVER PHARMACY, LLC

MEDICARE: 1 OLD RIVER 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
13336C0003XCommunity/Retail PharmacyFL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12909746OTHERFLFED ID

General Provider Information

NPI Number : 1952612970
Entity Type Code : Organization
Provider Name (Legal Business Name) : 1 OLD RIVER PHARMACY, LLC
Provider Business Mailing Address
First Line : 1879 NW 7TH ST
Second Line :
City : MIAMI
State : FL
Zip : 33125-3503
Country : US
Telephone Number : 305-477-6507
Fax Number : 305-477-6518
Provider Business Practice Location Address
First Line : 1879 NW 7TH ST
Second Line :
City : MIAMI
State : FL
Zip : 33125-3503
Country : US
Telephone Number : 305-477-6507
Fax Number : 305-477-6518
Authorized Official
Title or Position : PRESIDENT
Name : BEATRIZ CARREON
Credential :
Telephone Number : 305-477-6507
Provider Enumeration Date : 06/24/2010
Last Update Date : 06/24/2010

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Directions to “1 OLD RIVER PHARMACY, LLC ” Practice Location

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