=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922628544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE PHARMACY & MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2020
-----------------------------------------------------
Last Update Date | 04/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11200 SW VILLAGE PKWY STE 100
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-877-1125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11200 SW VILLAGE PKWY STE 100
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-877-1125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. RICARDO REID
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 305-766-3392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------