Provider Demographics
NPI:1699186353
Name:VITAL LIFE PHARMACY
Entity Type:Organization
Organization Name:VITAL LIFE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALAREZO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:954-871-7633
Mailing Address - Street 1:6063 SW 18TH ST
Mailing Address - Street 2:BAY 112
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7118
Mailing Address - Country:US
Mailing Address - Phone:561-245-7082
Mailing Address - Fax:
Practice Address - Street 1:6063 SW 18TH ST
Practice Address - Street 2:BAY 112
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7118
Practice Address - Country:US
Practice Address - Phone:561-245-7082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH281493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy