Provider Demographics
NPI:1427584044
Name:KMTV INC.
Entity Type:Organization
Organization Name:KMTV INC.
Other - Org Name:VISTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO/SEC./DIR.
Authorized Official - Prefix:
Authorized Official - First Name:MINH
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-821-7425
Mailing Address - Street 1:825 WASHINGTON BLVD.
Mailing Address - Street 2:STE. C
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-6179
Mailing Address - Country:US
Mailing Address - Phone:323-278-0016
Mailing Address - Fax:323-278-0019
Practice Address - Street 1:825 WASHINGTON BLVD.
Practice Address - Street 2:STE. C
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-6179
Practice Address - Country:US
Practice Address - Phone:323-278-0016
Practice Address - Fax:323-278-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CA555423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427594044Medicaid