Provider Demographics
NPI:1770565038
Name:PERGONQUI CORP
Entity type:Organization
Organization Name:PERGONQUI CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CABRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-887-6189
Mailing Address - Street 1:2030 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2620
Mailing Address - Country:US
Mailing Address - Phone:305-887-6189
Mailing Address - Fax:305-887-5370
Practice Address - Street 1:2030 PALM AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-2620
Practice Address - Country:US
Practice Address - Phone:305-887-6189
Practice Address - Fax:305-887-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28243336C0003X, 183500000X
FL031136701332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031136700Medicaid
FL0948520001Medicare NSC