1790120210 NPI number — BIOSCRIP MEDICAL SUPPLY SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790120210 NPI number — BIOSCRIP MEDICAL SUPPLY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIOSCRIP MEDICAL SUPPLY SERVICES, 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:
1790120210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10050 CROSSTOWN CIR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-3348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-979-3680
Provider Business Mailing Address Fax Number:
952-352-6698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 LUNDY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39401-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-267-4391
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
STALMACK
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP, GENERAL COUNSEL, SECRETARY
Authorized Official Telephone Number:
720-697-5153

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  12286/11.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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