Healthcare Provider Details

I. General information

NPI: 1538202981
Provider Name (Legal Business Name): VITHALLA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8573 SUDLEY RD STE B
MANASSAS VA
20110-3809
US

IV. Provider business mailing address

8573 SUDLEY RD STE B
MANASSAS VA
20110-3809
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-1332
  • Fax: 703-361-5496
Mailing address:
  • Phone: 703-361-1332
  • Fax: 703-361-5496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201002043
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KAMINI SHAH
Title or Position: OWNER
Credential: MA
Phone: 703-361-1332