Basic Information
| Provider Information | |||||||||
| NPI: | 1700914496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALDOMERO LOPEZ STATE VETERANS NURSING HOME | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BALDOMERO LOPEZ STATE VETERANS NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6919 PARKWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | LAND O LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346392909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135585000 | ||||||||
| FaxNumber: | 8135585018 | ||||||||
| Practice Location | |||||||||
| Address1: | 6919 PARKWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | LAND O LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346392909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135585000 | ||||||||
| FaxNumber: | 8135585018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRANDA | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8135585000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | PH16499 | FL | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2012484 | 01 | PK | OTHER | 021491400 | 05 | FL | MEDICAID |