MEDICARE: NUTRAVITA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	PHRE009650	GA
2	3336L0003X	Long Term Care Pharmacy
3	3336I0012X	Institutional Pharmacy	PHRE009650	GA

General Provider Information

NPI Number	:	1073839320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUTRAVITA, LLC

Provider Business Mailing Address
First Line	:	1560 FARMER RD NW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30012-3491
Country	:	US
Telephone Number	:	770-922-4466
Fax Number	:

Provider Business Practice Location Address
First Line	:	1560 FARMER RD NW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30012-3491
Country	:	US
Telephone Number	:	770-922-4466
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. NIKHIL M PATEL
Credential	:	RPH
Telephone Number	:	770-922-4466

Provider Enumeration Date	:	04/12/2010
Last Update Date	:	06/22/2026

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Directions to “NUTRAVITA, LLC ” Practice Location

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