1689677023 NPI number — EZ DIABETIC SUPPLIES, INC.

Table of content: (NPI 1689677023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689677023 NPI number — EZ DIABETIC SUPPLIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EZ DIABETIC SUPPLIES, INC.
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:
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:
1689677023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 STATE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BATH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04530-6301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-386-1080
Provider Business Mailing Address Fax Number:
207-386-1088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 STATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BATH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04530-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-386-1080
Provider Business Practice Location Address Fax Number:
207-386-1088
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZIMMERMAN
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-386-1080

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: 100249992-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2428733 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30762818 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90013939 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1344494 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810004618 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155450000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689677023 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZERO43692703001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 047029 . This is a "ANTHEM BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 200916420 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZERO3161800 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009975265 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010369258 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1017916 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 159235741 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689677023 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DM1153 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06559353 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689677023 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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