Provider Demographics
NPI:1760756316
Name:ESTONNA MANAGEMENT LLC
Entity Type:Organization
Organization Name:ESTONNA MANAGEMENT LLC
Other - Org Name:VITALITY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:239-992-7633
Mailing Address - Street 1:3501 HEALTH CENTER BLVD
Mailing Address - Street 2:#1200
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8127
Mailing Address - Country:US
Mailing Address - Phone:239-992-7633
Mailing Address - Fax:239-992-7896
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:#1200
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-992-7633
Practice Address - Fax:239-992-7896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH259543336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134226OtherPK