Organization
VINTAGE PHARMACY LLC
Active
Other names
VINTAGE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
PATTI HARRISON CPHT/RPT (OWNER AND PRESIDENT)
(352) 751-6895
Entity
Organization
Contact information
Practice address
104 S OLD DIXIE HWY, LADY LAKE, FL 32159-4349
(352) 751-6895
(352) 751-6894
Mailing address
PO BOX 67, LADY LAKE, FL 32158-0067
(352) 751-6895
(352) 751-6894
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH20910
FL
3336C0004X
Compounding Pharmacy
—
—
3336H0001X
Home Infusion Therapy Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
028308800
—
FL
01
—
2003982
PK
—
Enumeration date
06/21/2006
Last updated
01/09/2014
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