Provider Demographics
NPI:1083901938
Name:NORTHWEST MEDICAL PHARMACY LLC
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL PHARMACY LLC
Other - Org Name:NORTHWEST MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:ALEXEI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-637-6776
Mailing Address - Street 1:2089 SW 67TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1835
Mailing Address - Country:US
Mailing Address - Phone:305-637-6776
Mailing Address - Fax:305-637-3404
Practice Address - Street 1:2089 SW 67TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1835
Practice Address - Country:US
Practice Address - Phone:305-637-6776
Practice Address - Fax:305-637-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25535333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004301400Medicaid
5706392OtherNCPDP PROVIDER IDENTIFICATION NUMBER