=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578921094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MESA NEIGHBORHOOD PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2016
-----------------------------------------------------
Last Update Date | 06/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 E THOMAS RD SUITE 105
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-7646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-329-9585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 E THOMAS RD SUITE 105
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-7646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. VITTELIAN FORBES
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 602-237-6677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | Y006730
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------