Provider Demographics
NPI:1063469187
Name:VALLEY MEDICAL SHOPPE INC
Entity Type:Organization
Organization Name:VALLEY MEDICAL SHOPPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:AIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-356-7913
Mailing Address - Street 1:146 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1620
Mailing Address - Country:US
Mailing Address - Phone:208-356-7913
Mailing Address - Fax:
Practice Address - Street 1:146 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1620
Practice Address - Country:US
Practice Address - Phone:208-356-7913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY MEDICAL SHOPPE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME224332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0381930001Medicare NSC