Provider Demographics
NPI:1619424512
Name:EZ RX HALLANDALE LLC
Entity Type:Organization
Organization Name:EZ RX HALLANDALE LLC
Other - Org Name:EZ RX PHARMACY & COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-703-5670
Mailing Address - Street 1:1550 W 84TH ST
Mailing Address - Street 2:#62
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3379
Mailing Address - Country:US
Mailing Address - Phone:786-703-5670
Mailing Address - Fax:786-703-5657
Practice Address - Street 1:1550 W 84TH ST
Practice Address - Street 2:#62
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3379
Practice Address - Country:US
Practice Address - Phone:786-703-5670
Practice Address - Fax:786-703-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH30285333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163865OtherPK