MEDICARE: ST VINCENT DEPAUL VOLUNTEER COMMUNITY PHARMACY

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	3336C0002X	Clinic Pharmacy	PH17208	FL

General Provider Information

NPI Number	:	1396016945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST VINCENT DEPAUL VOLUNTEER COMMUNITY PHARMACY

Provider Business Mailing Address
First Line	:	21297 OLEAN BLVD UNIT B
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-4609
Country	:	US
Telephone Number	:	941-766-9570
Fax Number	:	941-249-4609

Provider Business Practice Location Address
First Line	:	21297 OLEAN BLVD UNIT B
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-4609
Country	:	US
Telephone Number	:	941-766-9570
Fax Number	:	941-249-4609

Authorized Official
Title or Position	:	PHARMACY DIRECTOR
Name	:	VALERIA FOGEL
Credential	:	PHARMD
Telephone Number	:	941-766-1584

Provider Enumeration Date	:	01/13/2012
Last Update Date	:	10/19/2022

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