Provider Demographics
NPI:1679647176
Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Other - Org Name:JACKSON MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ENEIDA
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROLDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-585-6754
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:PHARMACY ROOM ET BASEMENT 069
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-7458
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:PHARMACY ROOM WEST WING B-10
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-7458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL08293336I0012X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ0194922Medicare UPIN
100022Medicare ID - Type Unspecified