Basic Information
| Provider Information | |||||||||
| NPI: | 1912667502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JESSIE TRICE COMMUNITY HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLAMINGO PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5607 NW 27TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331422826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058051700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 E 10TH AVE STE 39 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330103766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058051700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2021 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | NEASMAN | ||||||||
| AuthorizedOfficialFirstName: | ANNIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3058051700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PH33639 | 01 | FL | STATE PHARMACY LICENSE | OTHER |