Provider Demographics
NPI:1962574723
Name:DOUGLAS GARDENS COMMUNITY MENTAL HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:DOUGLAS GARDENS COMMUNITY MENTAL HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELEANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LANSER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:305-531-5341
Mailing Address - Street 1:1680 MERIDIAN AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-2719
Mailing Address - Country:US
Mailing Address - Phone:305-531-5341
Mailing Address - Fax:
Practice Address - Street 1:1680 MERIDIAN AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-2719
Practice Address - Country:US
Practice Address - Phone:305-531-5341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH108543336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100730100Medicaid
FL1075630OtherNABP NUMBER
FL1075630OtherNABP NUMBER