Provider Demographics
NPI:1396985479
Name:DISCOUNT PHARMACY OF PINES LLC
Entity type:Organization
Organization Name:DISCOUNT PHARMACY OF PINES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUXELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-817-3577
Mailing Address - Street 1:12201 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1725
Mailing Address - Country:US
Mailing Address - Phone:954-885-4285
Mailing Address - Fax:866-232-2143
Practice Address - Street 1:12201 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1725
Practice Address - Country:US
Practice Address - Phone:954-885-4285
Practice Address - Fax:866-232-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH239023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01359000Medicaid
1043405OtherNCPDP PROVIDER IDENTIFICATION NUMBER