Provider Demographics
NPI:1396014064
Name:HEALTHCARE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:HEALTHCARE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FOKSHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-772-5333
Mailing Address - Street 1:4000 SE 82ND AVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-772-5333
Mailing Address - Fax:503-772-5366
Practice Address - Street 1:4000 SE 82ND AVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2924
Practice Address - Country:US
Practice Address - Phone:503-772-5333
Practice Address - Fax:503-772-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR653593332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274628Medicaid