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General NPI Number Information
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NPI Number | 1023354115
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Entity Type | Organization
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Legal Business Name | LA VIDA PHARMACY INC
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Dates
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Enumeration Date | 12/18/2012
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Last Update Date | 03/01/2017
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Provider Practice Location Address
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Address Line | 455 E MAIN ST
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City | EAST DUNDEE
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State | IL
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Zip | 60118-1529
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Country | US
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Telephone | 847-551-5379
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Fax | 224-484-8247
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Provider Business Mailing Address
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Address Line | 1412 PINE COVE CT
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City | DARIEN
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State | IL
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Zip | 60561-4999
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Country | US
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Telephone | 847-551-5379
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Fax | 224-484-8247
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Authorized Official
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Title or Position | OWNER, PHARMACIST
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Name | JITESH PATEL
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Credential | RPH
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Telephone | 847-551-5379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054.018817
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License Number State | IL
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