Healthcare Provider Details

I. General information

NPI: 1871168229
Provider Name (Legal Business Name): VITASOURCE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3806 AVENUE I STE 28
ROSENBERG TX
77471-3951
US

IV. Provider business mailing address

3806 AVENUE I STE 28
ROSENBERG TX
77471-3951
US

V. Phone/Fax

Practice location:
  • Phone: 844-744-0101
  • Fax: 844-744-0101
Mailing address:
  • Phone: 844-744-0101
  • Fax: 844-744-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAILENDRA GUPTA
Title or Position: OFFICER
Credential:
Phone: 844-843-0101