Provider Demographics
NPI:1770665564
Name:LAGE PHARMACY INC
Entity Type:Organization
Organization Name:LAGE PHARMACY INC
Other - Org Name:ABC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-649-3333
Mailing Address - Street 1:3485 W FLAGLER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-1042
Mailing Address - Country:US
Mailing Address - Phone:305-649-3333
Mailing Address - Fax:305-649-5722
Practice Address - Street 1:3485 W FLAGLER ST STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-1042
Practice Address - Country:US
Practice Address - Phone:305-649-3333
Practice Address - Fax:305-649-5722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH88873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025545900Medicaid
FL025545901Medicaid
1037022OtherNCPDP PROVIDER IDENTIFICATION NUMBER