Provider Demographics
NPI:1366844789
Name:AQUA PHARMACY INC
Entity Type:Organization
Organization Name:AQUA PHARMACY INC
Other - Org Name:AQUA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AGUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-525-9016
Mailing Address - Street 1:4243 W FLAGLER ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1605
Mailing Address - Country:US
Mailing Address - Phone:786-409-7503
Mailing Address - Fax:786-409-7516
Practice Address - Street 1:4243 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1605
Practice Address - Country:US
Practice Address - Phone:786-409-7503
Practice Address - Fax:786-409-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH285533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147892OtherPK