Provider Demographics
NPI:1134251796
Name:VIDA PHARMACY CORP
Entity type:Organization
Organization Name:VIDA PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAIMUNDO
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-822-8234
Mailing Address - Street 1:7250 W 24TH AVE
Mailing Address - Street 2:SUITE 19/20
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6575
Mailing Address - Country:US
Mailing Address - Phone:305-822-8234
Mailing Address - Fax:305-822-8246
Practice Address - Street 1:7250 W 24TH AVE
Practice Address - Street 2:SUITE 19/20
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6575
Practice Address - Country:US
Practice Address - Phone:305-822-8234
Practice Address - Fax:305-822-8246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH22588333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5960270001Medicare NSC