=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356629919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAHEALTH PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2011
-----------------------------------------------------
Last Update Date | 07/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4116 30TH AVE
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-2968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-777-8482
-----------------------------------------------------
Fax | 718-777-8489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4116 30TH AVE
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-2968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-777-8482
-----------------------------------------------------
Fax | 718-777-8489
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING PHARMACIST
-----------------------------------------------------
Name | SHERIN AYOUB
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 718-777-8482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 030825
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------