Provider Demographics
NPI:1740565860
Name:A NEW YOU PINK BOUTIQUE
Entity Type:Organization
Organization Name:A NEW YOU PINK BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-661-7465
Mailing Address - Street 1:106 W ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5112
Mailing Address - Country:US
Mailing Address - Phone:813-661-7465
Mailing Address - Fax:813-661-7465
Practice Address - Street 1:106 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5112
Practice Address - Country:US
Practice Address - Phone:813-661-7465
Practice Address - Fax:813-661-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier