Provider Demographics
NPI:1720592215
Name:VINE PHARMACY
Entity Type:Organization
Organization Name:VINE PHARMACY
Other - Org Name:VINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-925-2500
Mailing Address - Street 1:4375 RED ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:PA
Mailing Address - Zip Code:17814-7948
Mailing Address - Country:US
Mailing Address - Phone:570-925-2500
Mailing Address - Fax:570-925-5771
Practice Address - Street 1:4375 RED ROCK RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:PA
Practice Address - Zip Code:17814-7948
Practice Address - Country:US
Practice Address - Phone:570-925-2500
Practice Address - Fax:570-925-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4827633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy