{
"Npi": {
"NPI": "1396107249",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "VIVAWELL PHARMACY COMPANY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "72780 COUNTRY CLUB DR",
"SecondLineMailingAddress": "STE 403",
"MailingAddressCityName": "RANCHO MIRAGE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92270-4149",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "760-610-6512",
"MailingAddressFaxNumber": "760-610-6981",
"FirstLinePracticeLocationAddress": "72780 COUNTRY CLUB DR",
"SecondLinePracticeLocationAddress": "STE 403",
"PracticeLocationAddressCityName": "RANCHO MIRAGE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "92270-4149",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "760-610-6512",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/21/2016",
"LastUpdateDate": "10/03/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KIROYAN",
"AuthorizedOfficialFirstName": "JASON",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CEO/CFO/SEC/DIR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "909-647-7354",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "3336L0003X",
"TaxonomyName": "Long Term Care Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0004X",
"TaxonomyName": "Compounding Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "332BX2000X",
"TaxonomyName": "Oxygen Equipment & Supplies (DME)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "54279",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336S0011X",
"TaxonomyName": "Specialty Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "333600000X",
"TaxonomyName": "Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}