Provider Demographics
NPI:1235150293
Name:FLORIDA DEPARTMENTOF CHILDREN AND FAMILIES
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENTOF CHILDREN AND FAMILIES
Other - Org Name:S FL STATE HOSP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSP ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-392-3050
Mailing Address - Street 1:1317 WINEWOOD BLVD BLDG 2
Mailing Address - Street 2:OFFICE OF REVENUE MANAGEMENT, ATTN: VELMA BRYANT
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32399-0700
Mailing Address - Country:US
Mailing Address - Phone:850-921-8749
Mailing Address - Fax:954-392-3468
Practice Address - Street 1:800 E CYPRESS DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-4543
Practice Address - Country:US
Practice Address - Phone:954-392-3027
Practice Address - Fax:954-392-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X, 3336L0003X
FLPH162313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1018109OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL026004500Medicaid