Provider Demographics
NPI:1265488522
Name:MEDICALSHOPPE.COM, INC.
Entity Type:Organization
Organization Name:MEDICALSHOPPE.COM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSC, LLB
Authorized Official - Phone:323-340-3962
Mailing Address - Street 1:2501 COLORADO BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1055
Mailing Address - Country:US
Mailing Address - Phone:323-340-3962
Mailing Address - Fax:323-340-3963
Practice Address - Street 1:2501 COLORADO BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1055
Practice Address - Country:US
Practice Address - Phone:323-340-3962
Practice Address - Fax:323-340-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44021332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03315FMedicaid
CA5569890001Medicare NSC