Provider Demographics
NPI:1386680908
Name:VINTAGE PHARMACY LLC
Entity Type:Organization
Organization Name:VINTAGE PHARMACY LLC
Other - Org Name:VINTAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT/RPT
Authorized Official - Phone:352-751-6895
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-0067
Mailing Address - Country:US
Mailing Address - Phone:352-751-6895
Mailing Address - Fax:352-751-6894
Practice Address - Street 1:104 S OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-4349
Practice Address - Country:US
Practice Address - Phone:352-751-6895
Practice Address - Fax:352-751-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336H0001X, 3336L0003X, 3336S0011X
FLPH209103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003982OtherPK
FL028308800Medicaid
2003982OtherPK