Revive Pharmacy Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PH26342 Issued in FL

Legal business name

REVIVE PHARMACY INC

Doing business as

Revive Pharmacy

Practice address

16205 S Tamiami TRL
Suite # 6
Fort Myers, FL 33908-5304

Phone

(239) 204-4223

Fax

(239) 204-4224

NPI assigned

Sep 5, 2012

Last updated

Feb 26, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Nicole Deforte

Title

Owner

Phone

(239) 204-4223

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Revive Pharmacy Doing business as

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Locations

Networks

• Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Máximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
• Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1346803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456444800000",
    "number": "1558610527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16205 S TAMIAMI TRL",
            "address_2": "SUITE # 6",
            "city": "FORT MYERS",
            "state": "FL",
            "postal_code": "339085304",
            "telephone_number": "239-204-4223",
            "fax_number": "239-204-4224"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16205 S TAMIAMI TRL",
            "address_2": "SUITE # 6",
            "city": "FORT MYERS",
            "state": "FL",
            "postal_code": "339085304",
            "telephone_number": "239-204-4223",
            "fax_number": "239-204-4224"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-05",
        "last_updated": "2016-02-26",
        "status": "A",
        "authorized_official_last_name": "DEFORTE",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "239-204-4223"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "FL",
            "license": "PH26342",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2136822",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "006790300",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Revive Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Cori J. Revak, PSY.D.
• Tifani Megan Revels Lee, LMT
• Revitalize Counseling
• Revitalize Health Center LLC (Revitalize Health Care Center of Fort Myers)
• Revive Family Counseling, L.L.C.
• Manuel Revuelta, MD
• Gustavo Rey, MD
• Eric W Reyes Grajales, M.D.
• Danny Reyes Lopez
• Lenisse Reyes Reyes, MD

• Community/Retail Pharmacy in Fort Myers, FL
• Providers in Fort Myers, FL by specialty
• Community/Retail Pharmacy in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.