Provider Demographics
NPI:1952619033
Name:BLACK & WHITE PHARMACY CORP
Entity Type:Organization
Organization Name:BLACK & WHITE PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRMAYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIDALGO HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-545-2108
Mailing Address - Street 1:8381 BIRD RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3353
Mailing Address - Country:US
Mailing Address - Phone:305-545-2108
Mailing Address - Fax:305-545-2156
Practice Address - Street 1:8381 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3353
Practice Address - Country:US
Practice Address - Phone:305-545-2108
Practice Address - Fax:305-545-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25045310400000X, 3336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127589OtherPK
FL003611700Medicaid