Provider Demographics
NPI:1346276581
Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Other - Org Name:JACKSON MEMORIAL LTC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, CPH
Authorized Official - Phone:786-466-3000
Mailing Address - Street 1:2500 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-8429
Mailing Address - Country:US
Mailing Address - Phone:786-466-3000
Mailing Address - Fax:305-638-6880
Practice Address - Street 1:2500 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-8429
Practice Address - Country:US
Practice Address - Phone:786-466-3000
Practice Address - Fax:305-638-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH80343336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1026093OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL103277100Medicaid