Provider Demographics
NPI:1275585721
Name:HYPPOLITE, LAQUINTA W
Entity Type:Individual
Prefix:
First Name:LAQUINTA
Middle Name:W
Last Name:HYPPOLITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 SW 179TH WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-6303
Mailing Address - Country:US
Mailing Address - Phone:954-812-3843
Mailing Address - Fax:954-362-4739
Practice Address - Street 1:9021 TAFT ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-4676
Practice Address - Country:US
Practice Address - Phone:954-362-4738
Practice Address - Fax:954-362-4739
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 352521835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026089400Medicaid
FL4703090001Medicare ID - Type Unspecified