Provider Demographics
NPI:1811034119
Name:MALECON PHARMACY INC
Entity Type:Organization
Organization Name:MALECON PHARMACY INC
Other - Org Name:MALECON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLOVYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-558-8551
Mailing Address - Street 1:5966 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6814
Mailing Address - Country:US
Mailing Address - Phone:305-558-8551
Mailing Address - Fax:305-558-8512
Practice Address - Street 1:5966 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6814
Practice Address - Country:US
Practice Address - Phone:305-558-8551
Practice Address - Fax:305-558-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0003X, 3336S0011X
FLPH60793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003039900Medicaid
FL103293300Medicaid
FL103293301Medicaid
2004325OtherPK
FL103293301Medicaid