Provider Demographics
NPI:1427015718
Name:WESTERN DIABETIC SUPPLY CORPORATION
Entity Type:Organization
Organization Name:WESTERN DIABETIC SUPPLY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PLUMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-727-0080
Mailing Address - Street 1:3293 HARRISON BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1226
Mailing Address - Country:US
Mailing Address - Phone:877-937-8342
Mailing Address - Fax:866-808-3418
Practice Address - Street 1:3293 HARRISON BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1226
Practice Address - Country:US
Practice Address - Phone:877-937-8342
Practice Address - Fax:866-808-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1005116332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10051160000001OtherBLUECROSS/BLUE SHIELD
UT1028334OtherUNITED HEALTH CARE
UT=========001Medicaid
UT5058220001Medicare NSC