Provider Demographics
NPI:1104608009
Name:REVIVE RX
Entity type:Organization
Organization Name:REVIVE RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-946-6976
Mailing Address - Street 1:154 RAINBOW WAY UNIT 257
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3994
Mailing Address - Country:US
Mailing Address - Phone:770-946-6976
Mailing Address - Fax:972-777-5274
Practice Address - Street 1:1252 TODIWAY CT
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-6546
Practice Address - Country:US
Practice Address - Phone:770-946-6976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier