Provider Demographics
NPI:1477606713
Name:JOHNSTON MEDICAL SUPPLY
Entity Type:Organization
Organization Name:JOHNSTON MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:HOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-264-1201
Mailing Address - Street 1:2105 S 48TH ST
Mailing Address - Street 2:#105
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1019
Mailing Address - Country:US
Mailing Address - Phone:602-264-1201
Mailing Address - Fax:602-264-4970
Practice Address - Street 1:2105 S 48TH ST
Practice Address - Street 2:#105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1019
Practice Address - Country:US
Practice Address - Phone:602-264-1201
Practice Address - Fax:602-264-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X332B00000X
332BC3200X332BC3200X
335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0722360001Medicare ID - Type Unspecified