Provider Demographics
NPI:1568020311
Name:VINE BEAUTY SUPPLY
Entity Type:Organization
Organization Name:VINE BEAUTY SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PURNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-425-5778
Mailing Address - Street 1:615 RAHWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-3437
Mailing Address - Country:US
Mailing Address - Phone:732-425-5778
Mailing Address - Fax:800-745-6726
Practice Address - Street 1:615 RAHWAY AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-3437
Practice Address - Country:US
Practice Address - Phone:732-425-5778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1922270974Medicaid