Provider Demographics
NPI:1538202981
Name:VITHALLA, LLC
Entity type:Organization
Organization Name:VITHALLA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAMINI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:703-361-1332
Mailing Address - Street 1:8573 SUDLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-3809
Mailing Address - Country:US
Mailing Address - Phone:703-361-1332
Mailing Address - Fax:703-361-5496
Practice Address - Street 1:8573 SUDLEY RD STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3809
Practice Address - Country:US
Practice Address - Phone:703-361-1332
Practice Address - Fax:703-361-5496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
VA0201002043333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139157OtherPK