Provider Demographics
NPI:1164432126
Name:REISZ PHARMACEUTICALS VITAL CARE, INC.
Entity Type:Organization
Organization Name:REISZ PHARMACEUTICALS VITAL CARE, INC.
Other - Org Name:REISZ PHARMACEUTICALS VITAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:E
Authorized Official - Middle Name:
Authorized Official - Last Name:REISZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-683-7379
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 MAYFAIR DR
Practice Address - Street 2:MAYFAIR SQUARE PROFESSIONAL BUILDING
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4557
Practice Address - Country:US
Practice Address - Phone:270-683-7379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP02023332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54029384Medicaid
KY000000069966OtherBCBS
1445572OtherUMWA
KY90140302Medicaid
61128006OtherCHAMPUS/TRICARE
TN4055675OtherBCBS, NON-PAR
61128006OtherCHAMPUS/TRICARE
KY54029384Medicaid