MEDICARE: VITAL RX OF LOUISIANA 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY007506-IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2170664	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780108704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL RX OF LOUISIANA LLC

Provider Business Mailing Address
First Line	:	6200 LESLIE LANE
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-4772
Country	:	US
Telephone Number	:	877-264-8060
Fax Number	:	888-811-4564

Provider Business Practice Location Address
First Line	:	6200 LESLIE LANE
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-4772
Country	:	US
Telephone Number	:	877-264-8060
Fax Number	:	888-811-4564

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JOSEPH TATE
Credential	:
Telephone Number	:	337-304-9342

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	02/22/2022

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Directions to “VITAL RX OF LOUISIANA LLC ” Practice Location

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