Provider Demographics
NPI:1336895796
Name:THE VACCINE SHOPPE, LLC
Entity Type:Organization
Organization Name:THE VACCINE SHOPPE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMI LYNN
Authorized Official - Middle Name:KRISTIN
Authorized Official - Last Name:PANEK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-762-9132
Mailing Address - Street 1:200 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18643-2435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 BUTLER STREET
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640
Practice Address - Country:US
Practice Address - Phone:570-762-9132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332900000XSuppliersNon-Pharmacy Dispensing Site