Provider Demographics
NPI:1922401116
Name:VAL VISTA PHARMACY, LLC
Entity Type:Organization
Organization Name:VAL VISTA PHARMACY, LLC
Other - Org Name:SAROUJA GILBERT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-887-0244
Mailing Address - Street 1:3570 S. VAL VISTA DRIVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7327
Mailing Address - Country:US
Mailing Address - Phone:480-887-0244
Mailing Address - Fax:480-847-6868
Practice Address - Street 1:3570 S. VAL VISTA DRIVE
Practice Address - Street 2:SUITE 108
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7327
Practice Address - Country:US
Practice Address - Phone:480-887-0244
Practice Address - Fax:480-847-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY006086333600000X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY006086OtherSTATE PERMIT
AZ0044328Medicaid