Healthcare Provider Details

I. General information

NPI: 1073982120
Provider Name (Legal Business Name): VITALAB PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 E BELL RD STE 157 SUITE 157
PHOENIX AZ
85032
US

IV. Provider business mailing address

4045 E BELL RD STE 157 SUITE 157
PHOENIX AZ
85032-2240
US

V. Phone/Fax

Practice location:
  • Phone: 602-346-0204
  • Fax: 877-637-6691
Mailing address:
  • Phone: 602-346-0204
  • Fax: 877-637-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL VASILIAUSKAS
Title or Position: SR.V.P. BUSINESS DEVELOPMENT
Credential: PHARM D
Phone: 602-971-6950