Provider Demographics
NPI:1578350849
Name:LA, VIVIAN T
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:T
Last Name:LA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 E GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-2957
Mailing Address - Country:US
Mailing Address - Phone:714-722-2282
Mailing Address - Fax:
Practice Address - Street 1:1330 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8500
Practice Address - Country:US
Practice Address - Phone:714-547-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty