Healthcare Provider Details

I. General information

NPI: 1508253485
Provider Name (Legal Business Name): BLUE RIVER HQ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2015
Last Update Date: 04/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1394 US HIGHWAY 1
VERO BEACH FL
32960-5732
US

IV. Provider business mailing address

1965 NEWMARK CIR SW
VERO BEACH FL
32968-6711
US

V. Phone/Fax

Practice location:
  • Phone: 269-501-7034
  • Fax:
Mailing address:
  • Phone: 269-501-7034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. EMILY RAHEMI
Title or Position: OFFICE MANAGER
Credential: PTA
Phone: 269-501-7034