1639403470 NPI number — WESTERN MARYLAND MEDICAL SUPPLY, LLC

Table of content: (NPI 1639403470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639403470 NPI number — WESTERN MARYLAND MEDICAL SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN MARYLAND MEDICAL SUPPLY, LLC
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:
1639403470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12101 WINCHESTER RD
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
LAVALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502-7688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-729-4280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21550-1113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-533-4148
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
301-790-8102

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  R1119 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 421189800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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