Provider Demographics
NPI:1235394206
Name:DIABETES STORE, INCORPORATED
Entity Type:Organization
Organization Name:DIABETES STORE, INCORPORATED
Other - Org Name:DIABETES STORE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-646-3255
Mailing Address - Street 1:1760 MORIAH WOODS BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-7128
Mailing Address - Country:US
Mailing Address - Phone:901-312-3150
Mailing Address - Fax:800-208-0863
Practice Address - Street 1:7165 SWINNEA RD
Practice Address - Street 2:B-2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6360
Practice Address - Country:US
Practice Address - Phone:662-280-5533
Practice Address - Fax:800-208-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4425570002OtherMEDICARE
MS05033718Medicaid