Healthcare Provider Details

I. General information

NPI: 1902929565
Provider Name (Legal Business Name): MR. VIPUL B MAMTORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-5229
US

IV. Provider business mailing address

1360 ROBERTS RD
JACKSONVILLE FL
32259-8928
US

V. Phone/Fax

Practice location:
  • Phone: 844-224-8493
  • Fax:
Mailing address:
  • Phone: 904-233-3777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS37485
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: