Provider Demographics
NPI:1073257101
Name:GRACE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:GRACE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-557-6300
Mailing Address - Street 1:202 E BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9332
Mailing Address - Country:US
Mailing Address - Phone:509-557-6300
Mailing Address - Fax:509-557-6380
Practice Address - Street 1:203 2ND AVE S
Practice Address - Street 2:SUITE 112
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:509-557-6300
Practice Address - Fax:509-557-6380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JILL SCOTT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1912462649OtherNPI
WA1912462649Medicaid