Provider Demographics
NPI:1235612169
Name:GREEN MOUNTAIN MEDICAL STORE LLC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN MEDICAL STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MITALI
Authorized Official - Middle Name:R
Authorized Official - Last Name:ASHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-598-2697
Mailing Address - Street 1:46 FOX RUN RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 FOX RUN RD
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-2653
Practice Address - Country:US
Practice Address - Phone:802-598-2697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies