Provider Demographics
NPI:1750676110
Name:IN THE PINK BOUTIQUE, INC.
Entity Type:Organization
Organization Name:IN THE PINK BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERI
Authorized Official - Middle Name:KILLOUGH
Authorized Official - Last Name:MILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-372-0029
Mailing Address - Street 1:3547 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5309
Mailing Address - Country:US
Mailing Address - Phone:904-396-5515
Mailing Address - Fax:904-396-5516
Practice Address - Street 1:3547 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5309
Practice Address - Country:US
Practice Address - Phone:904-396-5515
Practice Address - Fax:904-396-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies