Provider Demographics
NPI:1376144733
Name:ANASO, VITALIS
Entity Type:Individual
Prefix:
First Name:VITALIS
Middle Name:
Last Name:ANASO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-2586
Mailing Address - Country:US
Mailing Address - Phone:972-926-6155
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-2586
Practice Address - Country:US
Practice Address - Phone:972-926-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist