Provider Demographics
NPI:1720024367
Name:PALM SHIRAZ
Entity Type:Organization
Organization Name:PALM SHIRAZ
Other - Org Name:MODERN MEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFC MGR
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALMODOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-613-3328
Mailing Address - Street 1:6860 SW 81 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6860 SW 81 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:305-740-5081
Practice Address - Fax:877-740-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21711333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1016852OtherOTHER ID NUMBER-COMMERCIAL NUMBER