Provider Demographics
NPI:1124213855
Name:MINIMED DISTRIBUTION CORP.
Entity Type:Organization
Organization Name:MINIMED DISTRIBUTION CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUATHASNANON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-550-2017
Mailing Address - Street 1:18000 DEVONSHIRE ST
Mailing Address - Street 2:ATTN: ANGELA WARD - LEGAL DEPT
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1219
Mailing Address - Country:US
Mailing Address - Phone:800-933-3322
Mailing Address - Fax:818-576-6228
Practice Address - Street 1:1800 PYRAMID PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-1703
Practice Address - Country:US
Practice Address - Phone:800-646-4633
Practice Address - Fax:818-739-4414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDTRONIC MINIMED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN611332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137682716Medicaid
TN1454129Medicaid