1366488199 NPI number — CUMBERLAND MEDICAL SUPPLY

Table of content: (NPI 1366488199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366488199 NPI number — CUMBERLAND MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUMBERLAND MEDICAL SUPPLY
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:
1366488199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4383 STONEBRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DESTIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32541-3463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-654-8939
Provider Business Mailing Address Fax Number:
850-654-8939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4105 S CHARLESTON PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45502-9375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-629-0962
Provider Business Practice Location Address Fax Number:
937-629-0980
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHEFFIELD
Authorized Official First Name:
W.
Authorized Official Middle Name:
BLAINE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-654-8939

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1455128 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810008256 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: R02256159 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101884075 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2052513 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100031700 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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