Provider Demographics
NPI:1225331788
Name:PINE RIDGE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:PINE RIDGE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESSIDENT/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOECKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-724-3460
Mailing Address - Street 1:146 N 3RD ST
Mailing Address - Street 2:P.O. BOX 408
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45176-1322
Mailing Address - Country:US
Mailing Address - Phone:513-724-3460
Mailing Address - Fax:513-724-3462
Practice Address - Street 1:146 N 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:OH
Practice Address - Zip Code:45176-1322
Practice Address - Country:US
Practice Address - Phone:513-724-3460
Practice Address - Fax:513-724-3462
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE RIDGE-PINE VILLAGE RES. HOMES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition