Provider Demographics
NPI:1154719524
Name:LA VIDA DISCOUNT PHARMACY INC
Entity type:Organization
Organization Name:LA VIDA DISCOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSIFUAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-215-3414
Mailing Address - Street 1:3204 KENSIGNTON AVE
Mailing Address - Street 2:1ST FL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134
Mailing Address - Country:US
Mailing Address - Phone:215-427-1603
Mailing Address - Fax:
Practice Address - Street 1:3204 KENSINGTON AVE FL 1
Practice Address - Street 2:1ST FL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1918
Practice Address - Country:US
Practice Address - Phone:215-427-1603
Practice Address - Fax:215-427-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
PAPP4825343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149600OtherPK
PA103007788Medicaid