| Entity Name: | VINTAGE PHARMACY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 02 Jul 2004 (21 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 10 Oct 2013 (11 years ago) |
| Document Number: | L04000049539 |
| FEI/EIN Number | 201402579 |
| Address: | 104 S. Old Dixie Hwy, Lady Lake, FL, 32159, US |
| Mail Address: | P.O. Box 67, Lady Lake, FL, 32158, US |
| ZIP code: | 32159 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386680908 | 2006-06-21 | 2014-01-09 | PO BOX 67, LADY LAKE, FL, 321580067, US | 104 S OLD DIXIE HWY, LADY LAKE, FL, 321594349, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 352-751-6895 |
| Fax | 3527516894 |
Authorized person
| Name | PATTI HARRISON |
| Role | OWNER AND PRESIDENT |
| Phone | 3527516895 |
Taxonomy
| Taxonomy Code | 332B00000X - Durable Medical Equipment & Medical Supplies |
| Is Primary | No |
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH20910 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3336C0004X - Compounding Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336H0001X - Home Infusion Therapy Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336L0003X - Long Term Care Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336S0011X - Specialty Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | PK |
| Number | 2003982 |
| Issuer | MEDICAID |
| Number | 028308800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| HARRISON PATTI M | Agent | 104 S. Old Dixie Hwy, Lady Lake, FL, 32159 |
| Name | Role | Address |
|---|---|---|
| HARRISON PATTI M | Manager | P.O. Box 67, Lady Lake, FL, 32158 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2018-04-24 | 104 S. Old Dixie Hwy, Lady Lake, FL 32159 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-04-24 | 104 S. Old Dixie Hwy, Lady Lake, FL 32159 | No data |
| CHANGE OF MAILING ADDRESS | 2018-04-24 | 104 S. Old Dixie Hwy, Lady Lake, FL 32159 | No data |
| REGISTERED AGENT NAME CHANGED | 2018-04-24 | HARRISON, PATTI M. | No data |
| REINSTATEMENT | 2013-10-10 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2013-09-27 | No data | No data |
| REINSTATEMENT | 2012-10-23 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2012-09-28 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-26 |
| ANNUAL REPORT | 2023-04-27 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-04-27 |
| ANNUAL REPORT | 2020-06-26 |
| ANNUAL REPORT | 2019-04-26 |
| ANNUAL REPORT | 2018-04-24 |
| ANNUAL REPORT | 2017-03-20 |
| ANNUAL REPORT | 2016-03-15 |
| ANNUAL REPORT | 2015-02-05 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
