Provider Demographics
NPI:1104009182
Name:ASSURED PHARMACY LAS VEGAS INC
Entity Type:Organization
Organization Name:ASSURED PHARMACY LAS VEGAS INC
Other - Org Name:ASSURED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF TECH OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-222-9971
Mailing Address - Street 1:17935 SKY PARK CIR
Mailing Address - Street 2:STE F
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 S RANCHO DR
Practice Address - Street 2:STE E3A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3854
Practice Address - Country:US
Practice Address - Phone:949-222-9971
Practice Address - Fax:949-271-5580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH022833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2990718OtherOTHER ID NUMBER