Provider Demographics
NPI:1811206915
Name:VITAL CARE SOUTHWEST VA, INC
Entity Type:Organization
Organization Name:VITAL CARE SOUTHWEST VA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-964-0555
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302
Mailing Address - Country:US
Mailing Address - Phone:601-482-7420
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:305 OLD KENTUCKY TURNPIKE
Practice Address - Street 2:
Practice Address - City:CEDAR BLUFF
Practice Address - State:VA
Practice Address - Zip Code:24609
Practice Address - Country:US
Practice Address - Phone:276-964-0555
Practice Address - Fax:276-964-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010040743336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA412247OtherANTHEM BCBS