=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790233518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINE HOSPITALITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 09/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 BEDFORD AVE 1ST FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-705-8386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 BEDFORD AVE 1ST FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-705-8386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING PHARMACIST
-----------------------------------------------------
Name | VINNIE DAM
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 949-705-8386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 034320
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------