Basic Information
| Provider Information | |||||||||
| NPI: | 1659092898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LA | ||||||||
| FirstName: | VICKI | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3223 VISTA LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774784423 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3080 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092125000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2022 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 71225 | TX | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 71225 | 01 | TX | TEXAS STATE BOARD OF PHARMACY | OTHER | 1379608 | 01 | NATIONAL ASSOCIATION OF BOARDS OF PHARMACY | OTHER |