Provider Demographics
NPI:1558876094
Name:MARINE PARK LLC
Entity type:Organization
Organization Name:MARINE PARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-552-2242
Mailing Address - Street 1:3514 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-2332
Mailing Address - Country:US
Mailing Address - Phone:561-782-7575
Mailing Address - Fax:855-230-7564
Practice Address - Street 1:3514 BROADWAY
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-2332
Practice Address - Country:US
Practice Address - Phone:561-782-7575
Practice Address - Fax:855-230-7564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH310593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100328900Medicaid
2177735OtherPK