Provider Demographics
NPI:1295827301
Name:ULTIMA RX LLC
Entity Type:Organization
Organization Name:ULTIMA RX LLC
Other - Org Name:ULTIMA RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:CUERVO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:305-557-9512
Mailing Address - Street 1:3900 NW 79TH AVENUE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-557-9512
Mailing Address - Fax:305-552-9291
Practice Address - Street 1:3900 NW 79TH AVENUE
Practice Address - Street 2:SUITE 216
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-557-9512
Practice Address - Fax:305-552-9291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH00195263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004621900Medicaid
FL5050920001Medicare NSC