1780746768 NPI number — VILLAGE MEDICAL SUPPLY,LLC.

Table of content: (NPI 1780746768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780746768 NPI number — VILLAGE MEDICAL SUPPLY,LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE 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:
1780746768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 SHERWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815-3085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-389-1161
Provider Business Mailing Address Fax Number:
570-389-1163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 SHERWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-3085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-389-1161
Provider Business Practice Location Address Fax Number:
570-389-1163
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUGO
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-652-7557

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  332BC3200X , 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)

  • Identifier: 1012127610002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529426 . This is a "WELLCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0018678 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2509434 . This is a "HIGHMARK BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 39H56 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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