Provider Demographics
NPI:1417968058
Name:1492 PHARMA GROUP CORP
Entity Type:Organization
Organization Name:1492 PHARMA GROUP CORP
Other - Org Name:MARCO DRUGS AND COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSPHARM
Authorized Official - Phone:305-665-4411
Mailing Address - Street 1:6420 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3302
Mailing Address - Country:US
Mailing Address - Phone:305-665-4411
Mailing Address - Fax:305-663-3258
Practice Address - Street 1:6420 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3302
Practice Address - Country:US
Practice Address - Phone:305-665-4411
Practice Address - Fax:305-663-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH220483336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007260700Medicaid
FL019180600Medicaid