Provider Demographics
NPI:1003509019
Name:VIVENT PHARMACY ILLINOIS LLC
Entity Type:Organization
Organization Name:VIVENT PHARMACY ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-223-6874
Mailing Address - Street 1:1311 N 6TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-4006
Mailing Address - Country:US
Mailing Address - Phone:800-359-9272
Mailing Address - Fax:833-368-1247
Practice Address - Street 1:5537 N BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1405
Practice Address - Country:US
Practice Address - Phone:888-655-2078
Practice Address - Fax:872-813-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy