Provider Demographics
NPI:1235548611
Name:PDL PHARMACY CORP
Entity Type:Organization
Organization Name:PDL PHARMACY CORP
Other - Org Name:PDL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:YORDY
Authorized Official - Middle Name:JULIAN
Authorized Official - Last Name:PONCE DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:786-443-4007
Mailing Address - Street 1:7167 W FLAGLER ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2601
Mailing Address - Country:US
Mailing Address - Phone:305-266-3705
Mailing Address - Fax:305-266-3706
Practice Address - Street 1:7167 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2601
Practice Address - Country:US
Practice Address - Phone:305-266-3705
Practice Address - Fax:305-266-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016223400Medicaid
FL016223400Medicaid