Healthcare Provider Details

I. General information

NPI: 1386680908
Provider Name (Legal Business Name): VINTAGE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S OLD DIXIE HWY
LADY LAKE FL
32159-4349
US

IV. Provider business mailing address

PO BOX 67
LADY LAKE FL
32158-0067
US

V. Phone/Fax

Practice location:
  • Phone: 352-751-6895
  • Fax: 352-751-6894
Mailing address:
  • Phone: 352-751-6895
  • Fax: 352-751-6894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH20910
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PATTI HARRISON
Title or Position: OWNER AND PRESIDENT
Credential: CPHT/RPT
Phone: 352-751-6895