1164460747 NPI number — MEDSTAR DIABETIC SUPPLY, LP

Table of content: (NPI 1164460747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164460747 NPI number — MEDSTAR DIABETIC SUPPLY, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSTAR DIABETIC SUPPLY, LP
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:
CCS MEDICAL
Provider Other Organization Name Type Code:
3
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:
1164460747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 LBJ FWY STE 1525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75234-7758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-628-2100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 W. GREEN OAKS BLVD
Provider Second Line Business Practice Location Address:
#205
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76016-2793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-535-5556
Provider Business Practice Location Address Fax Number:
866-535-5456
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOFMEISTER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
972-628-2100

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: 017085403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141003716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164460747 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100815120A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55424279 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009938430 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017085402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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