Provider Demographics
NPI:1164608360
Name:HOLLYWOOD PAIN RELIEF DISPENSARY
Entity Type:Organization
Organization Name:HOLLYWOOD PAIN RELIEF DISPENSARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CICELY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-789-4911
Mailing Address - Street 1:PO BOX 4688
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33338-4688
Mailing Address - Country:US
Mailing Address - Phone:954-376-7313
Mailing Address - Fax:954-697-0153
Practice Address - Street 1:3391 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3606
Practice Address - Country:US
Practice Address - Phone:954-963-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIAN'S CHOICE DISPENSING SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-17
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51845332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site