Provider Demographics
NPI:1376540294
Name:MY PHARMACY OF BIRD ROAD INC
Entity Type:Organization
Organization Name:MY PHARMACY OF BIRD ROAD INC
Other - Org Name:ALLEN'S MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AURELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:305-666-8582
Mailing Address - Street 1:4000 SW 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5318
Mailing Address - Country:US
Mailing Address - Phone:305-666-8582
Mailing Address - Fax:305-666-9110
Practice Address - Street 1:4000 SW 57TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5318
Practice Address - Country:US
Practice Address - Phone:305-666-8582
Practice Address - Fax:305-666-9110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28703332B00000X
333600000X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005251OtherPK
FL109383500Medicaid
0432340002Medicare NSC