Healthcare Provider Details

I. General information

NPI: 1396107249
Provider Name (Legal Business Name): VIVAWELL PHARMACY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2016
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72780 COUNTRY CLUB DR STE 403
RANCHO MIRAGE CA
92270-4149
US

IV. Provider business mailing address

72780 COUNTRY CLUB DR STE 403
RANCHO MIRAGE CA
92270-4149
US

V. Phone/Fax

Practice location:
  • Phone: 760-610-6512
  • Fax:
Mailing address:
  • Phone: 760-610-6512
  • Fax: 760-610-6981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number54279
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JASON KIROYAN
Title or Position: CEO/CFO/SEC/DIR
Credential:
Phone: 909-647-7354