Provider Demographics
NPI:1356641559
Name:COUNTRY CLUB PHARMACY AND DISCOUNT INC
Entity Type:Organization
Organization Name:COUNTRY CLUB PHARMACY AND DISCOUNT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-828-8600
Mailing Address - Street 1:5911 NW 173RD DR
Mailing Address - Street 2:# 6
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5121
Mailing Address - Country:US
Mailing Address - Phone:305-828-8600
Mailing Address - Fax:305-828-8630
Practice Address - Street 1:5911 NW 173RD DR
Practice Address - Street 2:# 6
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5121
Practice Address - Country:US
Practice Address - Phone:305-828-8600
Practice Address - Fax:305-828-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37199OtherDOCUMENT NUMBER