MEDICARE: IVNA PHARMACY SERVICES 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	3336C0003X	Community/Retail Pharmacy	2017040100	MO

General Provider Information

NPI Number	:	1265945216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVNA PHARMACY SERVICES LLC

Provider Business Mailing Address
First Line	:	1741 NE DOUGLAS ST STE 102
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64086-4704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 NE DOUGLAS ST STE 102
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64086-4704
Country	:	US
Telephone Number	:	636-544-4525
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VIKRANTH K ANNEBOINA
Credential	:
Telephone Number	:	636-544-4525

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	06/16/2018

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