=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063969574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VPRP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23653 EL TORO RD SUITE A
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-8614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-586-7780
-----------------------------------------------------
Fax | 949-586-3247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23653 EL TORO RD SUITE A
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-586-7780
-----------------------------------------------------
Fax | 949-586-3247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORP. SECRETARY
-----------------------------------------------------
Name | TOBIAS PORTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-586-7780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 53355
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------