=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295221067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIDA SANA PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8820 37TH AVE
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-433-9800
-----------------------------------------------------
Fax | 718-433-9898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8820 37TH AVE
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-433-9800
-----------------------------------------------------
Fax | 718-433-9898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WOEI CHEN LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-433-9800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 036632
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------