Healthcare Provider Details

I. General information

NPI: 1609056035
Provider Name (Legal Business Name): VIDA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 JEFFERSON ST NE STE D
ALBUQUERQUE NM
87113-1883
US

IV. Provider business mailing address

8500 JEFFERSON ST NE STE D
ALBUQUERQUE NM
87113-1883
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-1660
  • Fax: 505-856-7141
Mailing address:
  • Phone: 505-856-1660
  • Fax: 505-856-7141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH00002980
License Number StateNM

VIII. Authorized Official

Name: ANNABEL ROBERTS
Title or Position: OWNER
Credential: PHARMD
Phone: 505-856-1660