Provider Demographics
NPI:1053685610
Name:ONE SOURCE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ONE SOURCE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-977-1070
Mailing Address - Street 1:19606 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3246
Mailing Address - Country:US
Mailing Address - Phone:718-977-1070
Mailing Address - Fax:718-977-1072
Practice Address - Street 1:19606 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3246
Practice Address - Country:US
Practice Address - Phone:718-977-1070
Practice Address - Fax:718-228-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies