Provider Demographics
NPI:1215191952
Name:MAGNA EMPIRE GROUP INC
Entity Type:Organization
Organization Name:MAGNA EMPIRE GROUP INC
Other - Org Name:CORAL WEST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:NOHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:305-227-1174
Mailing Address - Street 1:2406 SW 137TH AVE
Mailing Address - Street 2:2406 SW 137TH AVE
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6311
Mailing Address - Country:US
Mailing Address - Phone:305-227-1174
Mailing Address - Fax:305-227-1171
Practice Address - Street 1:2406 SW 137TH AVE
Practice Address - Street 2:2406 SW 137TH AVE
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6311
Practice Address - Country:US
Practice Address - Phone:305-227-1174
Practice Address - Fax:305-227-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH234053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000230200Medicaid
1036260OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6112680001Medicare NSC