Provider Demographics
NPI:1427096809
Name:AETNA RX HOME DELIVERY
Entity type:Organization
Organization Name:AETNA RX HOME DELIVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR, PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TOKUNBO
Authorized Official - Middle Name:NIKE
Authorized Official - Last Name:KASSIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:959-299-3008
Mailing Address - Street 1:1600 SW 80TH TER FL 2
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4049
Mailing Address - Country:US
Mailing Address - Phone:866-612-3862
Mailing Address - Fax:
Practice Address - Street 1:1600 SW 80TH TER
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-4049
Practice Address - Country:US
Practice Address - Phone:954-693-2800
Practice Address - Fax:954-693-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21465333600000X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH21465OtherSTATE LICENSE
FLPH21465OtherSTATE LICENSE