Provider Demographics
NPI:1164537452
Name:DIABETES MANAGEMENT AND SUPPLIES
Entity Type:Organization
Organization Name:DIABETES MANAGEMENT AND SUPPLIES
Other - Org Name:DIABETES MANAGEMENT AND SUPPLES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSALESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-246-9499
Mailing Address - Street 1:220 W GERMANTOWN PIKE STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 COMMERCE CT
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70123-3200
Practice Address - Country:US
Practice Address - Phone:504-734-7165
Practice Address - Fax:504-734-7163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5274R332B00000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2208772Medicaid
2035208OtherPK
2035208OtherPK