Provider Demographics
NPI:1780868208
Name:VANDYGRIFF SHOES
Entity Type:Organization
Organization Name:VANDYGRIFF SHOES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IRWIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANLDYGRIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-745-4060
Mailing Address - Street 1:179 WOODELL ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-6929
Mailing Address - Country:US
Mailing Address - Phone:501-745-4060
Mailing Address - Fax:501-745-4012
Practice Address - Street 1:179 WOODELL ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6929
Practice Address - Country:US
Practice Address - Phone:501-745-4060
Practice Address - Fax:501-745-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID
4229910001Medicare NSC