1942205943 NPI number — KENTUCKY MEDICAL SUPPLY, INC.

Table of content: (NPI 1942205943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942205943 NPI number — KENTUCKY MEDICAL SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKY MEDICAL 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:
1942205943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3325 BARTLETT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32811-6428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-206-0040
Provider Business Mailing Address Fax Number:
407-206-0010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 CASTLE RIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-432-0957
Provider Business Practice Location Address Fax Number:
270-432-0957
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRIGGS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO/ PRESIDENT
Authorized Official Telephone Number:
407-206-0040

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 177855 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 175293 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45907789 . This is a "EPSDT PROVIDER ID NO." identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7542 . This is a "CHA PROVIDER ID NO." identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 90100058 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000070314 . This is a "BC PROVIDER ID NO." identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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