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General NPI Number Information
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NPI Number | 1336574003
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Entity Type | Organization
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Legal Business Name | WHOLE LIFE PHARMACY
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Dates
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Enumeration Date | 09/12/2013
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Last Update Date | 01/23/2014
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Provider Practice Location Address
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Address Line | 10575 DIXIE HWY
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City | PONTE VEDRA
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State | FL
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Zip | 32081
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Country | US
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Telephone | 904-827-0177
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Fax | 855-319-9872
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Provider Business Mailing Address
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Address Line | 2465 US 1 S STE 62
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6076
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Country | US
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Telephone | 904-827-0177
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Fax | 855-319-9872
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | MRS. TIFFANY AMBER HEATH
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Credential | PHARMD
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Telephone | 904-827-0177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH27103
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License Number State | FL
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