1417124496 NPI number — DIABETES MANAGEMENT AND SUPPLIES

Table of content: (NPI 1417124496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417124496 NPI number — DIABETES MANAGEMENT AND SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES MANAGEMENT AND SUPPLIES
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 MANAGEMENT AND SUPPLIES PHARMACY
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:
1417124496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2024
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:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 COMMERCE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70123-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-734-7165
Provider Business Practice Location Address Fax Number:
504-734-7163
Provider Enumeration Date:
05/09/2008

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: 333600000X , with the licence number:  5274IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2035626 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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