Provider Demographics
NPI:1598216467
Name:VITALAB PHARMACY INC
Entity Type:Organization
Organization Name:VITALAB PHARMACY INC
Other - Org Name:VASCO RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR.V.P. BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:VASILIAUSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-971-6950
Mailing Address - Street 1:4045 E BELL RD
Mailing Address - Street 2:SUITE 163
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-971-6950
Mailing Address - Fax:602-404-2504
Practice Address - Street 1:4045 E BELL RD
Practice Address - Street 2:SUITE 163
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2236
Practice Address - Country:US
Practice Address - Phone:602-971-6950
Practice Address - Fax:602-404-2504
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALERACARE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0047063336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ302331Medicaid
AZ6801710001Medicare NSC