Provider Demographics
NPI:1568578367
Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Other - Org Name:JACKSON MEMORIAL HOSPITAL OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-585-7979
Mailing Address - Street 1:PO BOX 12493
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-2493
Mailing Address - Country:US
Mailing Address - Phone:305-585-5315
Mailing Address - Fax:
Practice Address - Street 1:901 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1135
Practice Address - Country:US
Practice Address - Phone:305-585-5890
Practice Address - Fax:305-585-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH00082153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109498001Medicaid
2011957OtherPK
FL109498000Medicaid
FL109498001Medicaid