MEDICARE: VINTAGE VALLEY PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1215641469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINTAGE VALLEY PHARMACY LLC

Provider Business Mailing Address
First Line	:	1715 W KENNEWICK AVE
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-3378
Country	:	US
Telephone Number	:	509-361-1000
Fax Number	:	509-213-2822

Provider Business Practice Location Address
First Line	:	905 VINTAGE VALLEY PKWY UNIT E
Second Line	:
City	:	ZILLAH
State	:	WA
Zip	:	98953-9699
Country	:	US
Telephone Number	:	509-361-1000
Fax Number	:	509-213-2822

Authorized Official
Title or Position	:	CEO
Name	:	REDDY ANNAPPAREDDY
Credential	:
Telephone Number	:	509-841-0000

Provider Enumeration Date	:	01/12/2023
Last Update Date	:	02/19/2023

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