Provider Demographics
NPI:1376088849
Name:VESPER SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:VESPER SPECIALTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROGHLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:702-335-9601
Mailing Address - Street 1:4225 S EASTERN AVE STE 16
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5485
Mailing Address - Country:US
Mailing Address - Phone:702-333-4377
Mailing Address - Fax:702-333-0998
Practice Address - Street 1:4225 S EASTERN AVE STE 16
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5485
Practice Address - Country:US
Practice Address - Phone:702-333-4377
Practice Address - Fax:702-333-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NVPH036713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168129OtherPK