Organization
REVIVE PHARMACY INC
Active
Other names
Revive Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE DEFORTE (OWNER)
(239) 204-4223
Entity
Organization
Contact information
Practice address
16205 S TAMIAMI TRL, SUITE # 6, FORT MYERS, FL 33908-5304
(239) 204-4223
(239) 204-4224
Mailing address
16205 S TAMIAMI TRL, SUITE # 6, FORT MYERS, FL 33908-5304
(239) 204-4223
(239) 204-4224
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH26342
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
006790300
—
FL
01
—
2136822
PK
—
Enumeration date
09/05/2012
Last updated
02/26/2016
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