Provider Demographics
NPI:1871168229
Name:VITASOURCE PHARMACY LLC
Entity type:Organization
Organization Name:VITASOURCE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAILENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-843-0101
Mailing Address - Street 1:3806 AVENUE I STE 28
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3951
Mailing Address - Country:US
Mailing Address - Phone:844-744-0101
Mailing Address - Fax:844-744-0101
Practice Address - Street 1:3806 AVENUE I STE 28
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-3951
Practice Address - Country:US
Practice Address - Phone:844-744-0101
Practice Address - Fax:844-744-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33786OtherTEXAS STATE BOARD OF PHARMACY