Provider Demographics
NPI:1851725964
Name:VITALIS DRUGS LLC
Entity Type:Organization
Organization Name:VITALIS DRUGS LLC
Other - Org Name:VITALIS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHAMALLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:201-222-1800
Mailing Address - Street 1:3495 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-4119
Mailing Address - Country:US
Mailing Address - Phone:201-222-1800
Mailing Address - Fax:201-222-1811
Practice Address - Street 1:3495 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-4119
Practice Address - Country:US
Practice Address - Phone:201-222-1800
Practice Address - Fax:201-222-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NJ28RS007267003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0605590Medicaid
2141572OtherPK