Provider Demographics
NPI:1912931171
Name:PALMETTO BAY PHARMACY CORP
Entity Type:Organization
Organization Name:PALMETTO BAY PHARMACY CORP
Other - Org Name:PALMETTO BAY PHCY AND DISCOUNT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-205-3422
Mailing Address - Street 1:17035 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17035 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-4362
Practice Address - Country:US
Practice Address - Phone:305-969-2492
Practice Address - Fax:305-969-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH220403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1020320OtherOTHER ID NUMBER
1020320OtherOTHER ID NUMBER