Provider Demographics
NPI:1073982120
Name:VITALAB PHARMACY INC
Entity Type:Organization
Organization Name:VITALAB PHARMACY INC
Other - Org Name:VASCO INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR.V.P. BUSINESS DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VASILIAUSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:602-971-6950
Mailing Address - Street 1:4045 E BELL RD STE 157
Mailing Address - Street 2:SUITE 157
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2240
Mailing Address - Country:US
Mailing Address - Phone:602-346-0204
Mailing Address - Fax:877-637-6691
Practice Address - Street 1:4045 E BELL RD STE 157
Practice Address - Street 2:SUITE 157
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-346-0204
Practice Address - Fax:877-637-6691
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALERACARE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-18
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ302331Medicaid
AZ127832Medicaid
AZ6801710001Medicare NSC
AZZ165484Medicare PIN