Healthcare Provider Details

I. General information

NPI: 1972658151
Provider Name (Legal Business Name): VISTA PHARMACIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15791 BEAR VALLEY RD
HESPERIA CA
92345-1746
US

IV. Provider business mailing address

15791 BEAR VALLEY RD
HESPERIA CA
92345-1746
US

V. Phone/Fax

Practice location:
  • Phone: 760-956-1741
  • Fax: 760-956-1742
Mailing address:
  • Phone: 760-956-1741
  • Fax: 760-956-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY48290
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48290
License Number StateCA

VIII. Authorized Official

Name: MIKE VICK
Title or Position: PIC
Credential:
Phone: 909-908-0090