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General NPI Number Information
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NPI Number | 1730428897
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Entity Type | Organization
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Legal Business Name | AGEVITAL PHARMACY, LLC
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Dates
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Enumeration Date | 02/10/2013
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Last Update Date | 02/10/2013
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Provider Practice Location Address
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Address Line | 16 S BLVD OF THE PRESIDENTS
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City | SARASOTA
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State | FL
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Zip | 34236-1424
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Country | US
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Telephone | 941-928-8066
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Fax |
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Provider Business Mailing Address
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Address Line | 16 S BLVD OF THE PRESIDENTS
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City | SARASOTA
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State | FL
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Zip | 34236-1424
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Country | US
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Telephone | 941-928-8066
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Fax |
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Authorized Official
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Title or Position | PROPRIETOR/GENERAL MANAGER
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Name | JENNY P. WILKINS
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Credential |
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Telephone | 941-928-8066
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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 |
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License Number State |
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Taxonomy #2
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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 |
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