Provider Demographics
NPI:1770833386
Name:LA BUENA VIDA PHARMACY INC
Entity Type:Organization
Organization Name:LA BUENA VIDA PHARMACY INC
Other - Org Name:LA BUENA VIDA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:AOY YEE
Authorized Official - Last Name:YIK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:760-398-8866
Mailing Address - Street 1:51-335 CESAR CHAVEZ ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1547
Mailing Address - Country:US
Mailing Address - Phone:760-398-8866
Mailing Address - Fax:760-398-9966
Practice Address - Street 1:51-335 CESAR CHAVEZ ST
Practice Address - Street 2:SUITE 116
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1547
Practice Address - Country:US
Practice Address - Phone:760-398-8866
Practice Address - Fax:760-398-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY511583336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GY413AOtherMEDICARE PART B
56-45518OtherNCPDP
6721570001Medicare NSC