Healthcare Provider Details

I. General information

NPI: 1073839320
Provider Name (Legal Business Name): NUTRAVITA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 FARMER RD NW
CONYERS GA
30012-3491
US

IV. Provider business mailing address

1560 FARMER RD NW
CONYERS GA
30012-3491
US

V. Phone/Fax

Practice location:
  • Phone: 770-922-4466
  • Fax:
Mailing address:
  • Phone: 770-922-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPHRE009650
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHRE009650
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. NIKHIL M PATEL
Title or Position: PRESIDENT
Credential: RPH
Phone: 770-922-4466