Provider Demographics
NPI:1023540648
Name:EMERALD COAST MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:EMERALD COAST MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-420-2240
Mailing Address - Street 1:48 BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-8342
Mailing Address - Country:US
Mailing Address - Phone:850-420-2240
Mailing Address - Fax:850-344-9758
Practice Address - Street 1:48 BALD EAGLE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-420-2240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-02
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7EHGCOtherFLORIDA BLUE