Provider Demographics
NPI:1730615766
Name:WALDRUG LLC
Entity type:Organization
Organization Name:WALDRUG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:OCHOA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-444-8399
Mailing Address - Street 1:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:561-444-8399
Mailing Address - Fax:561-429-8115
Practice Address - Street 1:3387 S JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2010
Practice Address - Country:US
Practice Address - Phone:561-444-8399
Practice Address - Fax:561-653-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH311363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175717OtherPK
FL109478000Medicaid