Provider Demographics
NPI:1073757852
Name:NORTHWEST MEDICAL PHARMACY
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL PHARMACY
Other - Org Name:NORTHWEST MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-651-7074
Mailing Address - Street 1:671 NW 119TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-2522
Mailing Address - Country:US
Mailing Address - Phone:954-582-3602
Mailing Address - Fax:866-396-9179
Practice Address - Street 1:671 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-2522
Practice Address - Country:US
Practice Address - Phone:954-582-3602
Practice Address - Fax:866-396-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH240543336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053432OtherNCPDP PROVIDER IDENTIFICATION NUMBER