Healthcare Provider Details

I. General information

NPI: 1154750479
Provider Name (Legal Business Name): EN-VISION HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11349 BIG BEND RD
RIVERVIEW FL
33579-7183
US

IV. Provider business mailing address

11349 BIG BEND RD
RIVERVIEW FL
33579-7183
US

V. Phone/Fax

Practice location:
  • Phone: 813-672-8889
  • Fax:
Mailing address:
  • Phone: 813-672-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH27174
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH27174
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH27174
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH27174
License Number StateFL

VIII. Authorized Official

Name: MISS MADHUMATHI PULLELA
Title or Position: OWNER
Credential:
Phone: 813-784-5590