Provider Demographics
NPI:1518607712
Name:MEDINA, SUWANNEE
Entity Type:Individual
Prefix:
First Name:SUWANNEE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3557 W 94TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2080
Mailing Address - Country:US
Mailing Address - Phone:786-395-8218
Mailing Address - Fax:
Practice Address - Street 1:3557 W 94TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-2080
Practice Address - Country:US
Practice Address - Phone:786-395-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist