Provider Demographics
NPI:1265934723
Name:PINES DISCOUNT PHARMACY INC
Entity type:Organization
Organization Name:PINES DISCOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADEKUNLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADIMULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-437-4900
Mailing Address - Street 1:631 NW 100TH PL
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6163
Mailing Address - Country:US
Mailing Address - Phone:954-437-4900
Mailing Address - Fax:954-437-4504
Practice Address - Street 1:631 NW 100TH PL
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6163
Practice Address - Country:US
Practice Address - Phone:954-437-4900
Practice Address - Fax:954-437-4504
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINES DISCOUNT PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH241513336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030963000Medicaid