MEDICARE: VITSHANTA INC

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	PHY49260	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5633246	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1720225774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITSHANTA INC

Provider Business Mailing Address
First Line	:	4108 N SIERRA WAY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-3825
Country	:	US
Telephone Number	:	909-475-4250
Fax Number	:	909-882-4000

Provider Business Practice Location Address
First Line	:	4108 N SIERRA WAY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-3825
Country	:	US
Telephone Number	:	909-475-4250
Fax Number	:	909-882-4000

Authorized Official
Title or Position	:	RPH
Name	:	PRADEEP AMIN
Credential	:
Telephone Number	:	909-475-4250

Provider Enumeration Date	:	01/13/2009
Last Update Date	:	03/05/2012

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Directions to “VITSHANTA INC ” Practice Location

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