Provider Demographics
NPI:1033467402
Name:HERITAGE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:HERITAGE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBONUBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-322-7818
Mailing Address - Street 1:2005 MERRICK RD
Mailing Address - Street 2:202
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4644
Mailing Address - Country:US
Mailing Address - Phone:202-322-7818
Mailing Address - Fax:
Practice Address - Street 1:2005 MERRICK RD
Practice Address - Street 2:202
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4644
Practice Address - Country:US
Practice Address - Phone:202-322-7818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBN12003457332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies