Provider Demographics
NPI:1891982096
Name:LA VITA COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:LA VITA COMPOUNDING PHARMACY LLC
Other - Org Name:LA VITA COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIVANT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:858-453-2500
Mailing Address - Street 1:11468 SORRENTO VALLEY RD STE C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1347
Mailing Address - Country:US
Mailing Address - Phone:858-453-2500
Mailing Address - Fax:858-453-2501
Practice Address - Street 1:11468 SORRENTO VALLEY RD STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1347
Practice Address - Country:US
Practice Address - Phone:858-453-2500
Practice Address - Fax:858-453-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336M0002X
CA487313336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5628308OtherNCPDP PROVIDER IDENTIFICATION NUMBER