Basic Information
| Provider Information | |||||||||
| NPI: | 1477652428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIAN RIVER MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 36TH ST | ||||||||
| Address2: | RETAIL PHARMACY | ||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
| FaxNumber: | 7727941462 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 36TH ST | ||||||||
| Address2: | RETAIL PHARMACY | ||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
| FaxNumber: | 7727941462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SUSI | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.E.O. PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7725674311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PH-8926 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.