Provider Demographics
NPI:1790706471
Name:VITAL CARE PHARMACY OF NORFOLK, INC.
Entity Type:Organization
Organization Name:VITAL CARE PHARMACY OF NORFOLK, INC.
Other - Org Name:VITAL CARE PHARMACY OF NORFOLK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DEINES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:402-223-4779
Mailing Address - Street 1:120 N 27TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3286
Mailing Address - Country:US
Mailing Address - Phone:402-371-3444
Mailing Address - Fax:402-371-3566
Practice Address - Street 1:120 N 27TH ST STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3286
Practice Address - Country:US
Practice Address - Phone:402-371-3444
Practice Address - Fax:402-371-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X, 333600000X, 3336H0001X, 333600000X, 3336H0001X
NE2581333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE68053858100Medicaid
2816544OtherNCPDP
2816544OtherNCPDP
5731160001Medicare NSC