Basic Information
| Provider Information | |||||||||
| NPI: | 1649703232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTRO HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 S DADELAND BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331562824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054684185 | ||||||||
| FaxNumber: | 3056753378 | ||||||||
| Practice Location | |||||||||
| Address1: | 4675 LINTON BLVD | ||||||||
| Address2: | 202 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334456615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614955700 | ||||||||
| FaxNumber: | 5614952020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2017 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | BLUM | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIMARY PHARMACY PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5614955700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | ME52969 | 01 | FL | PRIMARY PHARMACY PHYSICIAN MEDICAL LICENSE | OTHER |