Healthcare Provider Details

I. General information

NPI: 1508097668
Provider Name (Legal Business Name): VITAL SHRED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E ATLANTIC BLVD STE 110
POMPANO BEACH FL
33060-7459
US

IV. Provider business mailing address

1000 E ATLANTIC BLVD STE:110
POMPANO BEACH FL
33060-7479
US

V. Phone/Fax

Practice location:
  • Phone: 954-366-6519
  • Fax: 954-366-6523
Mailing address:
  • Phone: 954-366-6519
  • Fax: 954-366-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24210
License Number StateFL

VIII. Authorized Official

Name: SERGE FRANCOIS
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 954-366-6519