Provider Demographics
NPI:1063465417
Name:INDIGO MEDICAL, INC.
Entity Type:Organization
Organization Name:INDIGO MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-263-2420
Mailing Address - Street 1:5927 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5037
Mailing Address - Country:US
Mailing Address - Phone:305-263-2420
Mailing Address - Fax:
Practice Address - Street 1:5927 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-5037
Practice Address - Country:US
Practice Address - Phone:305-263-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21873333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5537440001Medicare NSC