Healthcare Provider Details

I. General information

NPI: 1629296041
Provider Name (Legal Business Name): VISTA COMMUNITY CLINIC - PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

IV. Provider business mailing address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHY43164
License Number StateCA

VIII. Authorized Official

Name: MR. TRACY MUENZ
Title or Position: REVENUE MANAGER
Credential:
Phone: 760-726-0065