Provider Demographics
NPI:1972658151
Name:VISTA PHARMACIES, INC.
Entity Type:Organization
Organization Name:VISTA PHARMACIES, INC.
Other - Org Name:VALLEY VISTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-908-0090
Mailing Address - Street 1:15791 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1746
Mailing Address - Country:US
Mailing Address - Phone:760-956-1741
Mailing Address - Fax:760-956-1742
Practice Address - Street 1:15791 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1746
Practice Address - Country:US
Practice Address - Phone:760-956-1741
Practice Address - Fax:760-956-1742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY48290333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY48290OtherLICENSE
CAPHA482900Medicaid
CA5625186OtherNCPDP