Healthcare Provider Details

I. General information

NPI: 1093143570
Provider Name (Legal Business Name): ERGOGENIC LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2013
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11496 PIERSON RD STE C6
WELLINGTON FL
33414-8708
US

IV. Provider business mailing address

11496 PIERSON RD STE C6
WELLINGTON FL
33414-8708
US

V. Phone/Fax

Practice location:
  • Phone: 561-408-2361
  • Fax: 561-408-2365
Mailing address:
  • Phone: 561-408-2361
  • Fax: 561-408-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH27127
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTT MANGINI
Title or Position: PHARMACY MANAGER
Credential:
Phone: 561-408-2361