Provider Demographics
NPI:1467472670
Name:GONCAN, INC
Entity Type:Organization
Organization Name:GONCAN, INC
Other - Org Name:SOUTH BAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:NWAOBI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:561-992-9220
Mailing Address - Street 1:7050 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-3757
Mailing Address - Country:US
Mailing Address - Phone:954-962-2310
Mailing Address - Fax:561-992-9330
Practice Address - Street 1:155 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:SOUTH BAY
Practice Address - State:FL
Practice Address - Zip Code:33493-2213
Practice Address - Country:US
Practice Address - Phone:561-992-9220
Practice Address - Fax:561-992-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 138923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103475800Medicaid