Provider Demographics
NPI:1053664268
Name:PRESTIAGE PHARMACY AND MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:PRESTIAGE PHARMACY AND MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESSIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:IDANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENRIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-558-3848
Mailing Address - Street 1:2150 W 76TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1882
Mailing Address - Country:US
Mailing Address - Phone:305-558-3848
Mailing Address - Fax:305-558-3849
Practice Address - Street 1:2150 W 76TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1882
Practice Address - Country:US
Practice Address - Phone:305-558-3848
Practice Address - Fax:305-558-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH245853336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6367770001Medicare NSC