Provider Demographics
NPI:1356441687
Name:MICHIGAN DIABETES SUPPLIES LLC
Entity Type:Organization
Organization Name:MICHIGAN DIABETES SUPPLIES LLC
Other - Org Name:MICHIGAN DIABETES SUPPLIES LCC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EVERARD
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:DOMINY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-321-5290
Mailing Address - Street 1:4038 GRANGE HALL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1160
Mailing Address - Country:US
Mailing Address - Phone:800-321-5290
Mailing Address - Fax:248-634-2040
Practice Address - Street 1:4038 GRANGE HALL RD
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1160
Practice Address - Country:US
Practice Address - Phone:800-321-5290
Practice Address - Fax:248-634-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
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
MI2893512Medicaid
MI2893512Medicaid
MI03424500001Medicare ID - Type UnspecifiedMEDICARE REGION B