Basic Information
| Provider Information | |||||||||
| NPI: | 1194239780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL HOME ALLIANCE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMA WEST TAMPA DISPENSARY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 N HABANA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134449599 | ||||||||
| FaxNumber: | 8135138210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4078450330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | ACN515 | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 018418600 | 05 | FL | MEDICAID |