Provider Demographics
NPI:1851453468
Name:GUARDIAN PHARMACY OF SOUTHEAST FLORIDA LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF SOUTHEAST FLORIDA LLC
Other - Org Name:GUARDIAN PHARMACY OF SOUTHEAST FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-601-2121
Mailing Address - Street 1:GUARDIAN PHARMACY OF SOUTHEAST FLORIDA DEPT 2355
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0001
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:6100 BROKEN SOUND PKWY NW STE 1
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2790
Practice Address - Country:US
Practice Address - Phone:954-601-2121
Practice Address - Fax:954-601-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
FLPH229663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2004166OtherPK
FL032158300Medicaid
FL032158300Medicaid