Provider Demographics
NPI:1760784086
Name:VIVENT PHARMACY LLC
Entity Type:Organization
Organization Name:VIVENT PHARMACY LLC
Other - Org Name:VIVENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:414-223-6874
Mailing Address - Street 1:1311 N 6TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-4006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:833-368-1247
Practice Address - Street 1:1311 N 6TH ST STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-4006
Practice Address - Country:US
Practice Address - Phone:888-393-0351
Practice Address - Fax:833-368-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9049-423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128078OtherPK
WI100013165Medicaid