1487683942 NPI number — MEDICAL SUPPLY DEPOT

Table of content: (NPI 1487683942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487683942 NPI number — MEDICAL SUPPLY DEPOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL SUPPLY DEPOT
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:
Provider Other Organization Name Type Code:
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:
1487683942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4846 FLORENCE AVE.
Provider Second Line Business Mailing Address:
SUITE #B104
Provider Business Mailing Address City Name:
BELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90201-4399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-773-6522
Provider Business Mailing Address Fax Number:
323-773-8950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4846 FLORENCE AVE
Provider Second Line Business Practice Location Address:
SUITE #B104
Provider Business Practice Location Address City Name:
BELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90201-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-773-6522
Provider Business Practice Location Address Fax Number:
323-773-8950
Provider Enumeration Date:
06/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARROGA
Authorized Official First Name:
NORBERTO
Authorized Official Middle Name:
PURUGGANAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
323-773-6522

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  44656 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY 50801 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1487683942 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".