1780327122 NPI number — REJUVENATION PHARMACY INCORPORATED LLC

Table of content: (NPI 1780327122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780327122 NPI number — REJUVENATION PHARMACY INCORPORATED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENATION PHARMACY INCORPORATED LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780327122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
771 E SOUTHLAKE BLVD STE 223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-7065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-799-3879
Provider Business Mailing Address Fax Number:
281-335-6645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 NORWOOD DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HURST
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76054-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-799-3879
Provider Business Practice Location Address Fax Number:
281-335-6645
Provider Enumeration Date:
04/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAMIDANI
Authorized Official First Name:
ZARYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-844-8626

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com