Healthcare Provider Details

I. General information

NPI: 1841442019
Provider Name (Legal Business Name): VITA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2008
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5617 BELAIR RD
BALTIMORE MD
21206-3619
US

IV. Provider business mailing address

5617 BELAIR RD
BALTIMORE MD
21206-3619
US

V. Phone/Fax

Practice location:
  • Phone: 410-325-1641
  • Fax: 410-325-1642
Mailing address:
  • Phone: 410-325-1641
  • Fax: 410-325-1642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPW0319
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: IGOR CHERNYAKOVSKY
Title or Position: MANAGING MEMEBER
Credential:
Phone: 410-325-1641