Provider Demographics
NPI:1033648233
Name:MEDICAL HOME ALLIANCE LLC
Entity Type:Organization
Organization Name:MEDICAL HOME ALLIANCE LLC
Other - Org Name:IMA WINTER HAVEN DISPENSARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PICHARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-845-0330
Mailing Address - Street 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:199 AVENUE K SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4002
Practice Address - Country:US
Practice Address - Phone:863-299-6700
Practice Address - Fax:863-293-6359
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INHEALTH MD ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-09
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site