Healthcare Provider Details

I. General information

NPI: 1972604577
Provider Name (Legal Business Name): VISTA PHARMACIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15717 PARAMOUNT BLVD
PARAMOUNT CA
90723
US

IV. Provider business mailing address

15717 PARAMOUNT BLVD
PARAMOUNT CA
90723
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-8044
  • Fax:
Mailing address:
  • Phone: 562-630-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY45064
License Number StateCA

VIII. Authorized Official

Name: SAN DIEM LE
Title or Position: PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 562-630-8044