MEDICARE: VISTA SPECILTY PHARMACY

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH28734	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2149428	OTHER		PK

General Provider Information

NPI Number	:	1427303098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA SPECILTY PHARMACY

Provider Business Mailing Address
First Line	:	1500 OAKLEY SEAVER DR STE 3
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1974
Country	:	US
Telephone Number	:	352-989-5850
Fax Number	:	352-989-5849

Provider Business Practice Location Address
First Line	:	1500 OAKLEY SEAVER DR STE 3
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1974
Country	:	US
Telephone Number	:	352-989-5850
Fax Number	:	352-989-5849

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	SANDEEP MATHOW
Credential	:
Telephone Number	:	407-536-5696

Provider Enumeration Date	:	07/19/2012
Last Update Date	:	06/23/2016

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