Provider Demographics
NPI:1114978731
Name:FREESTATE MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:FREESTATE MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:M
Authorized Official - Last Name:VESTAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-897-8588
Mailing Address - Street 1:PO BOX 674553
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4553
Mailing Address - Country:US
Mailing Address - Phone:703-440-9320
Mailing Address - Fax:772-212-4904
Practice Address - Street 1:7830 BACKLICK RD STE 202
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-440-9320
Practice Address - Fax:772-212-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02917802Medicaid
NE100259473-00Medicaid
MD012424900Medicaid
IL020600937Medicaid
PA101897930Medicaid
WA1114978731Medicaid
NM88905314Medicaid
VA1114978731Medicaid
DC55790700Medicaid
IA1114978731Medicaid