1770912511 NPI number — MAIN LINE MEDICAL SUPPLIES

Table of content: MR. GREGORY LLOYD WASHINGTON CP (NPI 1497907810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770912511 NPI number — MAIN LINE MEDICAL SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE MEDICAL 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:
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:
1770912511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 S 69TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER DARBY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19082-4213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-734-0800
Provider Business Mailing Address Fax Number:
610-734-1326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2635 WESTFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08105-1132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-365-1211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BERNHARDT
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
610-734-0800

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  5003351 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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