MEDICARE: VINLABA GREENVILLE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	28RS00453500	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2058010	OTHER		PK

General Provider Information

NPI Number	:	1194886960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINLABA GREENVILLE PHARMACY INC

Provider Business Mailing Address
First Line	:	1850 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-2122
Country	:	US
Telephone Number	:	201-433-8002
Fax Number	:	201-433-4655

Provider Business Practice Location Address
First Line	:	1850 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-2122
Country	:	US
Telephone Number	:	201-433-8002
Fax Number	:	201-433-4655

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	GOPAL DARISIPUDI
Credential	:
Telephone Number	:	201-433-8002

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	05/04/2015

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