Provider Demographics
NPI:1417108184
Name:MAR-LAC PHARMACY DISCOUNT & SUPPLY CORP
Entity Type:Organization
Organization Name:MAR-LAC PHARMACY DISCOUNT & SUPPLY CORP
Other - Org Name:MAR-LAC PHARMACY DISCOUNT & SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-631-6602
Mailing Address - Street 1:1109 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-2738
Mailing Address - Country:US
Mailing Address - Phone:305-631-6602
Mailing Address - Fax:305-631-6603
Practice Address - Street 1:1109 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-2738
Practice Address - Country:US
Practice Address - Phone:305-631-6602
Practice Address - Fax:305-631-6603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
FLPH236013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126986OtherPK
2126986OtherPK
FLFM1743803OtherDEA
FL6137520001Medicare NSC
FL1038353OtherNCPDP
FL6137520001OtherPTAN