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General NPI Number Information
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NPI Number | 1093143570
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Entity Type | Organization
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Legal Business Name | ERGOGENIC LABS LLC
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Dates
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Enumeration Date | 10/21/2013
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Last Update Date | 12/19/2013
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Provider Practice Location Address
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Address Line | 11496 PIERSON RD STE C6
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City | WELLINGTON
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State | FL
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Zip | 33414-8708
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Country | US
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Telephone | 561-408-2361
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Fax | 561-408-2365
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Provider Business Mailing Address
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Address Line | 11496 PIERSON RD STE C6
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City | WELLINGTON
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State | FL
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Zip | 33414-8708
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Country | US
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Telephone | 561-408-2361
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Fax | 561-408-2365
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | SCOTT MANGINI
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Credential |
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Telephone | 561-408-2361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | PH27127
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License Number State | FL
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