1669428124 NPI number — GRANDIFF MEDICAL SUPPLIES INC

Table of content: (NPI 1669428124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669428124 NPI number — GRANDIFF MEDICAL SUPPLIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANDIFF MEDICAL 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:
6
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:
1669428124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 VITAL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20904-3446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-388-0596
Provider Business Mailing Address Fax Number:
301-388-0597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 VITAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20904-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-388-0596
Provider Business Practice Location Address Fax Number:
301-388-0597
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AKPAETE
Authorized Official First Name:
IMAOBONG
Authorized Official Middle Name:
NNSEWO
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
301-388-0596

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  R2253 , 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: 027061500 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009119175 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 414364700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10079260 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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