Provider Demographics
NPI:1427303098
Name:VISTA SPECILTY PHARMACY
Entity type:Organization
Organization Name:VISTA SPECILTY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SANDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-536-5696
Mailing Address - Street 1:1500 OAKLEY SEAVER DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1974
Mailing Address - Country:US
Mailing Address - Phone:352-989-5850
Mailing Address - Fax:352-989-5849
Practice Address - Street 1:1500 OAKLEY SEAVER DR STE 3
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1974
Practice Address - Country:US
Practice Address - Phone:352-989-5850
Practice Address - Fax:352-989-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH287343336C0003X
FLPH262413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149428OtherPK