Provider Demographics
NPI:1376634873
Name:PACIFIC MEDICAL SUPPLY
Entity Type:Organization
Organization Name:PACIFIC MEDICAL SUPPLY
Other - Org Name:PACIFIC MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FIDELIS
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:EKONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-552-0322
Mailing Address - Street 1:574 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-5846
Mailing Address - Country:US
Mailing Address - Phone:951-553-0322
Mailing Address - Fax:951-279-6004
Practice Address - Street 1:574 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-5846
Practice Address - Country:US
Practice Address - Phone:951-553-0322
Practice Address - Fax:951-279-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
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
TX162054401/02Medicaid
TX162054401/02Medicaid