Provider Demographics
NPI:1962592915
Name:CITRUS HEALTH NETWORK, INC.
Entity type:Organization
Organization Name:CITRUS HEALTH NETWORK, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:JARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-825-0300
Mailing Address - Street 1:4175 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5874
Mailing Address - Country:US
Mailing Address - Phone:305-825-0300
Mailing Address - Fax:305-556-2580
Practice Address - Street 1:4175 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-424-3177
Practice Address - Fax:305-556-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH87033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105376100Medicaid
2005744OtherPK