Provider Demographics
NPI:1730261033
Name:PRESTAB CO
Entity type:Organization
Organization Name:PRESTAB CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASULTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-599-7000
Mailing Address - Street 1:3016 NW 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1010
Mailing Address - Country:US
Mailing Address - Phone:305-599-1643
Mailing Address - Fax:305-599-1663
Practice Address - Street 1:3016 NW 79TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1010
Practice Address - Country:US
Practice Address - Phone:305-599-1643
Practice Address - Fax:305-599-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH194623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02697010Medicaid
FL02697010Medicaid