1174708705 NPI number — EMBRY MEDICAL SUPPLY

Table of content: (NPI 1174708705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174708705 NPI number — EMBRY MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMBRY MEDICAL SUPPLY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EMBRY WELDING SUPPLY, INC.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174708705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 INDUSTRIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANEYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42721-9176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-879-9287
Provider Business Mailing Address Fax Number:
270-879-3405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 INDUSTRIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANEYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42721-9176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-879-9287
Provider Business Practice Location Address Fax Number:
270-879-3405
Provider Enumeration Date:
01/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EMBRY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COOWNER
Authorized Official Telephone Number:
270-879-9287

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1051288 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 90010430 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2433002000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 45901287 . This is a "MEDICIAD EPSDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000070263 . This is a "BC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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