Provider Demographics
NPI:1790233518
Name:VINE HOSPITALITY, LLC
Entity Type:Organization
Organization Name:VINE HOSPITALITY, LLC
Other - Org Name:EQUILIBRIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:949-705-8386
Mailing Address - Street 1:320 BEDFORD AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-4368
Mailing Address - Country:US
Mailing Address - Phone:949-705-8386
Mailing Address - Fax:
Practice Address - Street 1:320 BEDFORD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-4368
Practice Address - Country:US
Practice Address - Phone:949-705-8386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0343203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy