Provider Demographics
NPI:1366742132
Name:PAYNE, VINCENT I
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:I
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-9294
Mailing Address - Country:US
Mailing Address - Phone:310-677-0501
Mailing Address - Fax:310-677-0053
Practice Address - Street 1:500 E MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-9294
Practice Address - Country:US
Practice Address - Phone:310-677-0501
Practice Address - Fax:310-677-0053
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41275183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist