Grey Dog IV, Inc
Organization Active NPI Community/Retail Pharmacy · Key Biscayne, FL
NPI 1275019705 · NPPES record last updated Jul 18, 2018
Key facts
- NPI
- 1275019705
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- PH31442 (FL)
- Legal business name
- GREY DOG IV, INC
- Practice address
- 260 Crandon Blvd Ste 33
Key Biscayne, FL 33149-1538 - Phone
- (305) 982-8727
- NPI assigned
- Jul 18, 2018
- Organization subpart
- No
Authorized official
- Name
- Rafael Parra, RPT, CPHT
- Title
- Treasurer
- Phone
- (305) 781-7768
Practitioners 1
-
Javier Diaz, PHARMD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2151726 | Ethos Wellness Pharmacy | Certificate of waiver | Jul 25, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in FL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20200715000729 | FL | Part B Supplier - Independent Clinical Laboratory | 8628491289 | Practice locations: Key Biscayne, FL |
| O20200715001634 | FL | Part B Supplier - Pharmacy | 8628491289 | Practice locations: Key Biscayne, FL |
National Provider Directory
Locations
260 Crandon Blvd
Ste 33
Key Biscayne, FL 33149
Phone (305) 982-8727
Networks
- HealthSun Health Plans Network
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | PH31442 | FL | Yes |
Addresses
Primary practice location
260 Crandon Blvd Ste 33
Key Biscayne, FL 33149-1538
Mailing address
260 Crandon Blvd Ste 33
Key Biscayne, FL 33149-1538
Phone (305) 982-8727
Other names
- Ethos Wellness Pharmacy
Other providers in Key Biscayne, FL
- Guillermina Giardinelli
- Chloe Marie Godward
- Roland Manuel Gracia
- Graciela C Pozo Mdpa
- Stephanie Grail
- Ramon A Guevara
- Mae Gutierrez
- Natalie Suzanne Guzman
- Valentina Heinz
- Hernandez Lea Plaza Dental
All providers in Key Biscayne, FL · Community/Retail Pharmacy in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 18, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.