1891722898 NPI number — EXPRESS MEDICAL & NUTRITION SUPPLY INC.

Table of content: (NPI 1891722898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891722898 NPI number — EXPRESS MEDICAL & NUTRITION SUPPLY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPRESS MEDICAL & NUTRITION SUPPLY 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:
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:
1891722898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6201 JOHNS RD
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-885-3444
Provider Business Mailing Address Fax Number:
813-885-1729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 JOHNS RD
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33634-4434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-885-3444
Provider Business Practice Location Address Fax Number:
813-885-1729
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PICKENS
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
813-885-3444

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  3980120428317 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BP3500X , with the licence number: 3980120428317 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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