Provider Demographics
NPI:1700914496
Name:BALDOMERO LOPEZ STATE VETERANS NURSING HOME
Entity Type:Organization
Organization Name:BALDOMERO LOPEZ STATE VETERANS NURSING HOME
Other - Org Name:BALDOMERO LOPEZ STATE VETERANS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-558-5000
Mailing Address - Street 1:6919 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-2909
Mailing Address - Country:US
Mailing Address - Phone:813-558-5000
Mailing Address - Fax:813-558-5018
Practice Address - Street 1:6919 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-2909
Practice Address - Country:US
Practice Address - Phone:813-558-5000
Practice Address - Fax:813-558-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH164993336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012484OtherPK
FL021491400Medicaid