Provider Demographics
NPI:1346226172
Name:MACOMB MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:MACOMB MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:586-790-5867
Mailing Address - Street 1:36562 MORAVIAN DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1202
Mailing Address - Country:US
Mailing Address - Phone:586-790-5867
Mailing Address - Fax:586-790-5916
Practice Address - Street 1:36562 MORAVIAN DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1202
Practice Address - Country:US
Practice Address - Phone:586-790-5867
Practice Address - Fax:586-790-5916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3271301Medicaid
MI540EO04450OtherBCBS
MI540EO04450OtherBCBS