Healthcare Provider Details

I. General information

NPI: 1407734775
Provider Name (Legal Business Name): VITALIY ZNAKHARCHUK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone: 904-819-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS64608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: