Provider Demographics
NPI:1437359676
Name:I&M GRAND MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:I&M GRAND MEDICAL SUPPLIES
Other - Org Name:IVAN MANUCHARYAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUCHARYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-934-3752
Mailing Address - Street 1:5826 W OLIVE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3153
Mailing Address - Country:US
Mailing Address - Phone:623-934-3752
Mailing Address - Fax:623-934-3725
Practice Address - Street 1:5826 W OLIVE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3153
Practice Address - Country:US
Practice Address - Phone:623-934-3752
Practice Address - Fax:623-934-3725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20174034332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies