Provider Demographics
NPI:1003223108
Name:PALM BEACH PHARMA CORP
Entity type:Organization
Organization Name:PALM BEACH PHARMA CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:P/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ILDIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:SIPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-650-0236
Mailing Address - Street 1:PO BOX 2134
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33480-2134
Mailing Address - Country:US
Mailing Address - Phone:561-650-0236
Mailing Address - Fax:561-650-0237
Practice Address - Street 1:235 PERUVIAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33480-4695
Practice Address - Country:US
Practice Address - Phone:561-650-0236
Practice Address - Fax:561-650-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH281393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012723900Medicaid
2147000OtherPK