MEDICARE: REJUVENATION PHARMACY INCORPORATED LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3336M0002X	Mail Order Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	3336S0011X	Specialty Pharmacy

General Provider Information

NPI Number	:	1780327122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REJUVENATION PHARMACY INCORPORATED LLC

Provider Business Mailing Address
First Line	:	1550 NORWOOD DR STE 300
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76054-3653
Country	:	US
Telephone Number	:	281-336-9927
Fax Number	:	281-335-6645

Provider Business Practice Location Address
First Line	:	1550 NORWOOD DR STE 300
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76054-3653
Country	:	US
Telephone Number	:	888-799-3879
Fax Number	:	281-335-6645

Authorized Official
Title or Position	:	CHIEF PHARMACY OFFICER
Name	:	CHRISTOPHER VARD TYRONE II
Credential	:	PHARMD
Telephone Number	:	682-438-2904

Provider Enumeration Date	:	04/14/2022
Last Update Date	:	04/23/2026

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