=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659830487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE PHARMACY & MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2019
-----------------------------------------------------
Last Update Date | 05/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11200 SW VILLAGE PKWY STE 100
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-877-1125
-----------------------------------------------------
Fax | 772-800-5039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11200 SW VILLAGE PKWY STE 100
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-877-1125
-----------------------------------------------------
Fax | 772-800-5039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | RICARDO REID
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 772-877-1125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------