Provider Demographics
NPI:1356508980
Name:PHYTOGENICS LLC
Entity type:Organization
Organization Name:PHYTOGENICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOLIERE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH MPH
Authorized Official - Phone:954-612-5831
Mailing Address - Street 1:4501 NW 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3403
Mailing Address - Country:US
Mailing Address - Phone:954-612-5831
Mailing Address - Fax:800-532-0764
Practice Address - Street 1:4501 NW 31ST AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-3403
Practice Address - Country:US
Practice Address - Phone:954-612-5831
Practice Address - Fax:800-532-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336M0003X, 3336S0011X, 335G00000X
FLPH232513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No335G00000XSuppliersMedical Foods Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
2011517OtherPK
FL006744800Medicaid