Provider Demographics
NPI:1104116573
Name:FLORIDA DEPARTMENT OF HEALTH IN MIAMI-DADE COUNTY
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH IN MIAMI-DADE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-845-0164
Mailing Address - Street 1:2515 W FLAGLER STREET
Mailing Address - Street 2:102-A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135
Mailing Address - Country:US
Mailing Address - Phone:305-643-7400
Mailing Address - Fax:305-643-7401
Practice Address - Street 1:2515 W FLAGLER STREET
Practice Address - Street 2:102-A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135
Practice Address - Country:US
Practice Address - Phone:305-643-7400
Practice Address - Fax:305-643-7401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-19
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X
FLPH74563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH7456OtherPHARMACY LICENSE