Provider Demographics
NPI:1306863360
Name:WESTERN MARYLAND MEDICAL SUPPLY
Entity Type:Organization
Organization Name:WESTERN MARYLAND MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-790-8102
Mailing Address - Street 1:12101 WINCHESTER RD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7688
Mailing Address - Country:US
Mailing Address - Phone:301-729-4280
Mailing Address - Fax:301-729-2944
Practice Address - Street 1:12101 WINCHESTER RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7688
Practice Address - Country:US
Practice Address - Phone:301-729-4280
Practice Address - Fax:301-729-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR1119332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD411305500Medicaid
MD411305500Medicaid