Provider Demographics
NPI:1285191478
Name:DIABETES STORE, INCORPORATED
Entity Type:Organization
Organization Name:DIABETES STORE, INCORPORATED
Other - Org Name:DIABETES AND RESPIRATORY STORE
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:
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 1:1760 MORIAH WOODS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-7128
Practice Address - Country:US
Practice Address - Phone:901-312-3150
Practice Address - Fax:800-208-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4451679OtherNCPDP