Healthcare Provider Details

I. General information

NPI: 1760784086
Provider Name (Legal Business Name): VIVENT PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N 6TH ST STE 101
MILWAUKEE WI
53212-4006
US

IV. Provider business mailing address

1311 N 6TH ST STE 201
MILWAUKEE WI
53212-4006
US

V. Phone/Fax

Practice location:
  • Phone: 888-393-0351
  • Fax: 833-368-1247
Mailing address:
  • Phone:
  • Fax: 833-368-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9049-42
License Number StateWI

VIII. Authorized Official

Name: TONY FIELDS
Title or Position: CHIEF PHARMACY OFFICER
Credential: PHARMD
Phone: 414-223-6874