Provider Demographics
NPI:1629158829
Name:TUDELA PHARMACY, INC.
Entity Type:Organization
Organization Name:TUDELA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:MAGADALENA
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-223-4841
Mailing Address - Street 1:10981 SW 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4412
Mailing Address - Country:US
Mailing Address - Phone:305-223-4841
Mailing Address - Fax:305-223-1006
Practice Address - Street 1:10981 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4412
Practice Address - Country:US
Practice Address - Phone:305-223-4841
Practice Address - Fax:305-223-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH14292333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1079385OtherNABP
FL022874500Medicaid
BT7695185OtherDEA
FL1158200001Medicare PIN
FL1158200001Medicare NSC