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General NPI Number Information
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NPI Number | 1194470682
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Entity Type | Organization
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Legal Business Name | THE VACCINE SHOPPE, LLC
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Dates
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Enumeration Date | 02/14/2022
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Last Update Date | 02/14/2022
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Provider Practice Location Address
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Address Line | 205 BUTLER ST
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City | PITTSTON
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State | PA
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Zip | 18640
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Country | US
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Telephone | 570-762-9132
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Fax |
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Provider Business Mailing Address
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Address Line | 205 BUTLER ST
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City | PITTSTON
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State | PA
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Zip | 18640
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Country | US
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Telephone | 570-762-9132
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUDE POLIT-MORAN
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Credential |
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Telephone | 570-718-8406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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