Provider Demographics
NPI:1609056035
Name:VIDA PHARMACY LLC
Entity Type:Organization
Organization Name:VIDA PHARMACY LLC
Other - Org Name:VIDA PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-856-1660
Mailing Address - Street 1:8500 JEFFERSON ST NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1883
Mailing Address - Country:US
Mailing Address - Phone:505-856-1660
Mailing Address - Fax:505-856-7141
Practice Address - Street 1:8500 JEFFERSON ST NE
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1883
Practice Address - Country:US
Practice Address - Phone:505-856-1660
Practice Address - Fax:505-856-7141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPH000029803336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2059025OtherPK