Provider Demographics
NPI:1235141854
Name:MARION MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:MARION MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CORREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-451-4461
Mailing Address - Street 1:2508 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2714
Mailing Address - Country:US
Mailing Address - Phone:916-451-4461
Mailing Address - Fax:916-451-4049
Practice Address - Street 1:2508 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2714
Practice Address - Country:US
Practice Address - Phone:916-451-4461
Practice Address - Fax:916-451-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44380332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03308FMedicaid
CADME03308FMedicaid