Provider Demographics
NPI:1205861804
Name:ACTIVE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:ACTIVE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:HULLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-975-9100
Mailing Address - Street 1:1416 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3668
Mailing Address - Country:US
Mailing Address - Phone:813-975-9100
Mailing Address - Fax:813-975-8886
Practice Address - Street 1:1416 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3668
Practice Address - Country:US
Practice Address - Phone:813-975-9100
Practice Address - Fax:813-975-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1243890001Medicare ID - Type Unspecified