1033142948 NPI number — HEALTHY LIVING MEDICAL SUPPLY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033142948 NPI number — HEALTHY LIVING MEDICAL SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY LIVING MEDICAL SUPPLY, LLC
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:
HEALTHY LIVING DIABETIC LLC
Provider Other Organization Name Type Code:
4
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:
1033142948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 W GERMANTOWN PIKE STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH MEETING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19462-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-630-6357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 VERMONT ST STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48216-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-779-8512
Provider Business Practice Location Address Fax Number:
866-779-8511
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSALESI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO
Authorized Official Telephone Number:
484-246-9499

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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