=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376088849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VESPER SPECIALTY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2016
-----------------------------------------------------
Last Update Date | 03/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4225 S EASTERN AVE STE 16
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-333-4377
-----------------------------------------------------
Fax | 702-333-0998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4225 S EASTERN AVE STE 16
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-333-4377
-----------------------------------------------------
Fax | 702-333-0998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PIC, AO
-----------------------------------------------------
Name | JOSHUA KOROGHLI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 702-335-9601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH03671
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------