Provider Demographics
NPI:1710486410
Name:VITAL RX LLC
Entity Type:Organization
Organization Name:VITAL RX LLC
Other - Org Name:VITAL RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEBOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-209-5540
Mailing Address - Street 1:237 CAHABA VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1146
Mailing Address - Country:US
Mailing Address - Phone:866-209-5540
Mailing Address - Fax:800-878-4160
Practice Address - Street 1:237 CAHABA VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1146
Practice Address - Country:US
Practice Address - Phone:866-209-5540
Practice Address - Fax:800-878-4160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
AL1146293336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL189993Medicaid
2175777OtherPK