Provider Demographics
NPI:1063463883
Name:PINECREST PHARMACY, INC
Entity Type:Organization
Organization Name:PINECREST PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:GAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-253-9191
Mailing Address - Street 1:955 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-1274
Mailing Address - Country:US
Mailing Address - Phone:305-253-9191
Mailing Address - Fax:
Practice Address - Street 1:955 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1274
Practice Address - Country:US
Practice Address - Phone:305-253-9191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4741240001Medicare ID - Type UnspecifiedPROVIDER NUMBER