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General NPI Number Information
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NPI Number | 1780108704
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Entity Type | Organization
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Legal Business Name | VITAL RX OF LOUISIANA LLC
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Dates
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Enumeration Date | 08/01/2017
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Last Update Date | 02/22/2022
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Provider Practice Location Address
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Address Line | 6200 LESLIE LANE
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City | LAKE CHARLES
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State | LA
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Zip | 70615-4772
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Country | US
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Telephone | 877-264-8060
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Fax | 888-811-4564
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Provider Business Mailing Address
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Address Line | 6200 LESLIE LANE
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City | LAKE CHARLES
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State | LA
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Zip | 70615-4772
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Country | US
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Telephone | 877-264-8060
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Fax | 888-811-4564
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Authorized Official
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Title or Position | DIRECTOR
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Name | JOSEPH TATE
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Credential |
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Telephone | 337-304-9342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY007506-IR
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License Number State | LA
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