Provider Demographics
NPI:1487410247
Name:MED VAULT INC
Entity type:Organization
Organization Name:MED VAULT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SIMEON
Authorized Official - Middle Name:OSITA
Authorized Official - Last Name:NWEGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-422-4315
Mailing Address - Street 1:4621 WATERS EDGE LN NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6238
Mailing Address - Country:US
Mailing Address - Phone:404-422-4315
Mailing Address - Fax:
Practice Address - Street 1:5060 ALLATOONA GTWY
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4906
Practice Address - Country:US
Practice Address - Phone:678-653-9036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-27
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy