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General NPI Number Information
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NPI Number | 1508253485
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Entity Type | Organization
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Legal Business Name | BLUE RIVER HQ, LLC
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Dates
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Enumeration Date | 04/18/2015
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Last Update Date | 04/18/2015
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Provider Practice Location Address
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Address Line | 1394 US HIGHWAY 1
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City | VERO BEACH
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State | FL
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Zip | 32960-5732
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Country | US
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Telephone | 269-501-7034
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Fax |
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Provider Business Mailing Address
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Address Line | 1965 NEWMARK CIR SW
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City | VERO BEACH
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State | FL
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Zip | 32968-6711
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Country | US
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Telephone | 269-501-7034
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. EMILY RAHEMI
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Credential | PTA
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Telephone | 269-501-7034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State | FL
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