=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396107249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIVAWELL PHARMACY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2016
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72780 COUNTRY CLUB DR STE 403
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-610-6512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72780 COUNTRY CLUB DR STE 403
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-610-6512
-----------------------------------------------------
Fax | 760-610-6981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/CFO/SEC/DIR
-----------------------------------------------------
Name | JASON KIROYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-647-7354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 54279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------