Healthcare Provider Details

I. General information

NPI: 1619107240
Provider Name (Legal Business Name): VISTA COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 GRAPEVINE RD
VISTA CA
92083-4004
US

IV. Provider business mailing address

134 GRAPEVINE RD
VISTA CA
92083-4004
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-5030
  • Fax: 760-414-3754
Mailing address:
  • Phone: 760-631-5030
  • Fax: 760-414-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number49951
License Number StateCA

VIII. Authorized Official

Name: BARBARA MANNINO
Title or Position: CEO
Credential:
Phone: 760-631-5000