Provider Demographics
NPI:1023011053
Name:VINE DISCOUNT PHARMACY & MEDICAL SUPPLY
Entity Type:Organization
Organization Name:VINE DISCOUNT PHARMACY & MEDICAL SUPPLY
Other - Org Name:VINE DISCOUNT PHARMACY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:323-957-9446
Mailing Address - Street 1:1253 N VINE ST
Mailing Address - Street 2:SUITE #11
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1662
Mailing Address - Country:US
Mailing Address - Phone:323-957-9446
Mailing Address - Fax:323-957-9846
Practice Address - Street 1:1253 N VINE ST
Practice Address - Street 2:STE 11
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1662
Practice Address - Country:US
Practice Address - Phone:323-957-9446
Practice Address - Fax:323-957-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY465063336C0003X
CA465063336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54097OtherPHARMACIST-IN-CHARGE LIC#
CAPHA465060Medicaid
CA5607489OtherNCPDP
CAPHY46506OtherSITE PERMIT
CAPHY46506OtherSITE PERMIT