Provider Demographics
NPI:1730189523
Name:MEDICOR HEALTHCHOICE INC
Entity type:Organization
Organization Name:MEDICOR HEALTHCHOICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-250-4468
Mailing Address - Street 1:2200 NW 102 AVENUE SUITE 2B
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2225
Mailing Address - Country:US
Mailing Address - Phone:800-250-4468
Mailing Address - Fax:888-614-4949
Practice Address - Street 1:2200 NW 102 AVENUE SUITE 2B
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2225
Practice Address - Country:US
Practice Address - Phone:800-250-4468
Practice Address - Fax:888-614-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHME051332BP3500X
FLPH260713336S0011X
FLPH260703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682074300Medicaid
FL951866500Medicaid
FLPH26071OtherPHARMACY LICENSE
FLHME051OtherAHCA
FLPH26070OtherPHARMACY LICENSE
1123190001Medicare ID - Type Unspecified