1164460747 NPI number — MEDSTAR DIABETIC SUPPLY, LP

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 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:
Provider Other Organization Name Type Code:
6
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:
10/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 FOUNTAIN PKWY N STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33716-1411
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:
3030 LBJ FWY STE 1525
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75234-7758
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:
CHIEF OPERATING & FINANCIAL OFFICER
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: 017085402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009938430 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141003716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55424279 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100815120A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164460747 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017085403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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