=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043340409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL CARE OF CENTRAL ALABAMA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 248 KEYSTONE DRIVE
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-2975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-280-4175
-----------------------------------------------------
Fax | 205-280-4182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 248 KEYSTONE DRIVE
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-2975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-280-4175
-----------------------------------------------------
Fax | 205-280-4182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARK THOMPSON CONRADI
-----------------------------------------------------
Credential | R.PH., J.D.
-----------------------------------------------------
Telephone | 205-280-4176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 112749
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------