1235394206 NPI number — DIABETES STORE, INCORPORATED

Table of content: (NPI 1235394206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235394206 NPI number — DIABETES STORE, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES STORE, INCORPORATED
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:
DIABETES STORE, INC.
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:
1235394206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 MORIAH WOODS BLVD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38117-7128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-312-3150
Provider Business Mailing Address Fax Number:
800-208-0863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7165 SWINNEA RD
Provider Second Line Business Practice Location Address:
B-2
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-6360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-280-5533
Provider Business Practice Location Address Fax Number:
800-208-0863
Provider Enumeration Date:
07/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BROSSEAU
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-646-3255

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: 4425570002 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 05033718 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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