Provider Demographics
NPI:1356845689
Name:WAYNE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:WAYNE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:GHOSN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-908-4510
Mailing Address - Street 1:26808 SIMONE ST.
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS.
Mailing Address - State:MI
Mailing Address - Zip Code:48127
Mailing Address - Country:US
Mailing Address - Phone:313-903-5151
Mailing Address - Fax:313-908-4510
Practice Address - Street 1:26808 SIMONE ST.
Practice Address - Street 2:
Practice Address - City:DEARBORN HTS.
Practice Address - State:MI
Practice Address - Zip Code:48127
Practice Address - Country:US
Practice Address - Phone:313-903-5151
Practice Address - Fax:313-908-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies