Provider Demographics
NPI:1730298563
Name:HERSEN INC
Entity Type:Organization
Organization Name:HERSEN INC
Other - Org Name:SAN JOSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:YAILKA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-266-1234
Mailing Address - Street 1:2666 SW 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2666 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2031
Practice Address - Country:US
Practice Address - Phone:305-229-1300
Practice Address - Fax:305-229-1532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH00152723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1064764OtherOTHER ID NUMBER
1064764OtherOTHER ID NUMBER