Provider Demographics
NPI:1225540263
Name:EYE CANDY BEAUTY SUPPLY
Entity Type:Organization
Organization Name:EYE CANDY BEAUTY SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:DUSHAWN
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-657-7558
Mailing Address - Street 1:200 BRADDOCK ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2208
Mailing Address - Country:US
Mailing Address - Phone:304-657-7558
Mailing Address - Fax:
Practice Address - Street 1:208 ADAMS ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2826
Practice Address - Country:US
Practice Address - Phone:304-368-0027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier