| Entity Name: | REVIVE PHARMACY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 10 May 2012 (13 years ago) |
| Document Number: | P12000043993 |
| FEI/EIN Number | 45-5246441 |
| Address: | 16205 SOUTH TAMIAMI TRAIL, SUITE 6, FORT MYERS, FL 33908 |
| Mail Address: | 16205 SOUTH TAMIAMI TRAIL, SUITE 6, FORT MYERS, FL 33908 |
| ZIP code: | 33908 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558610527 | 2012-09-05 | 2016-02-26 | 16205 S TAMIAMI TRL, SUITE # 6, FORT MYERS, FL, 339085304, US | 16205 S TAMIAMI TRL, SUITE # 6, FORT MYERS, FL, 339085304, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 239-204-4223 |
| Fax | 2392044224 |
Authorized person
| Name | NICOLE DEFORTE |
| Role | OWNER |
| Phone | 2392044223 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH26342 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PK |
| Number | 2136822 |
| Issuer | MEDICAID |
| Number | 006790300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DEFORTE, NICOLE | Agent | 16205 SOUTH TAMIAMI TRAIL, SUITE 6, FORT MYERS, FL 33908 |
| Name | Role | Address |
|---|---|---|
| DEFORTE, NICOLE | President | 16205 SOUTH TAMIAMI TRAIL, SUITE 6 FORT MYERS, FL 33908 |
| Name | Role | Address |
|---|---|---|
| Deforte, Fidel | Finance Officer | 16205 SOUTH TAMIAMI TRAIL, SUITE 6 FORT MYERS, FL 33908 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-02-28 | 16205 SOUTH TAMIAMI TRAIL, SUITE 6, FORT MYERS, FL 33908 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-01 |
| ANNUAL REPORT | 2023-02-28 |
| ANNUAL REPORT | 2022-03-08 |
| ANNUAL REPORT | 2021-02-03 |
| ANNUAL REPORT | 2020-03-27 |
| ANNUAL REPORT | 2019-02-04 |
| ANNUAL REPORT | 2018-04-23 |
| ANNUAL REPORT | 2017-03-21 |
| ANNUAL REPORT | 2016-01-22 |
| ANNUAL REPORT | 2015-02-02 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4049447704 | 2020-05-01 | 0455 | PPP | 16205 S TAMIAMI TRAIL UNIT #6, FORT MYERS, FL, 33908 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Date of last update: 22 Feb 2025
Sources: Florida Department of State
