Basic Information
| Provider Information | |||||||||
| NPI: | 1558580464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5617336663 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334454616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612092570 | ||||||||
| FaxNumber: | 8442066435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5618045885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD CPH | ||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PH13006 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 018382100 | 05 | FL | MEDICAID | 2004123 | 01 | PK | OTHER |