Provider Demographics
NPI:1437121365
Name:HAVANA LTC PHARMACY INC
Entity Type:Organization
Organization Name:HAVANA LTC PHARMACY INC
Other - Org Name:HAVANA LTC PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAMILET
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-875-5914
Mailing Address - Street 1:3818 S HIMES AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1413
Mailing Address - Country:US
Mailing Address - Phone:813-875-5914
Mailing Address - Fax:813-875-5924
Practice Address - Street 1:3818 S HIMES AVE STE 1
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1413
Practice Address - Country:US
Practice Address - Phone:813-875-5914
Practice Address - Fax:813-875-5924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH214243336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030971100Medicaid
2005033OtherPK