MEDICARE: IN THE PINK BOUTIQUE, INC.

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	332B00000X	Durable Medical Equipment & Medical Supplies		FL

General Provider Information

NPI Number	:	1750676110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IN THE PINK BOUTIQUE, INC.

Provider Business Mailing Address
First Line	:	3547 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5309
Country	:	US
Telephone Number	:	904-396-5515
Fax Number	:	904-396-5516

Provider Business Practice Location Address
First Line	:	3547 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5309
Country	:	US
Telephone Number	:	904-396-5515
Fax Number	:	904-396-5516

Authorized Official
Title or Position	:	CEO
Name	:	JERI KILLOUGH MILLARD
Credential	:
Telephone Number	:	904-372-0029

Provider Enumeration Date	:	06/14/2011
Last Update Date	:	01/07/2019

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