Provider Demographics
NPI:1063714111
Name:CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:CORAL GABLES PHARMACY AND MEDICAL SUPPLY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-444-5115
Mailing Address - Street 1:3160 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6826
Mailing Address - Country:US
Mailing Address - Phone:305-444-5115
Mailing Address - Fax:305-444-5119
Practice Address - Street 1:3160 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6826
Practice Address - Country:US
Practice Address - Phone:305-444-5115
Practice Address - Fax:305-444-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336M0002X
FLPH250663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5702786OtherNCPDP PROVIDER IDENTIFICATION NUMBER