Provider Demographics
NPI:1033325667
Name:MEDTECH MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:MEDTECH MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:OLAWALE
Authorized Official - Middle Name:AYOOLA
Authorized Official - Last Name:OYETIBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-962-7580
Mailing Address - Street 1:PO BOX 2098
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91769-2098
Mailing Address - Country:US
Mailing Address - Phone:626-962-7580
Mailing Address - Fax:626-960-1659
Practice Address - Street 1:1331 W GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2242
Practice Address - Country:US
Practice Address - Phone:626-962-7580
Practice Address - Fax:626-960-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49380332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6148400001Medicare NSC