Provider Demographics
NPI:1922838101
Name:COMPUTER MELON SHOP, LLC
Entity type:Organization
Organization Name:COMPUTER MELON SHOP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SUPPORT BROKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-519-9072
Mailing Address - Street 1:10 BROOK DR S
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 BROOK DR S
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-2220
Practice Address - Country:US
Practice Address - Phone:845-519-9072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPUTER MELON SHOP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage