Provider Demographics
NPI:1487683942
Name:MEDICAL SUPPLY DEPOT
Entity Type:Organization
Organization Name:MEDICAL SUPPLY DEPOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NORBERTO
Authorized Official - Middle Name:PURUGGANAN
Authorized Official - Last Name:BARROGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-773-6522
Mailing Address - Street 1:4846 FLORENCE AVE.
Mailing Address - Street 2:SUITE #B104
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4399
Mailing Address - Country:US
Mailing Address - Phone:323-773-6522
Mailing Address - Fax:323-773-8950
Practice Address - Street 1:4846 FLORENCE AVE
Practice Address - Street 2:SUITE #B104
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-4317
Practice Address - Country:US
Practice Address - Phone:323-773-6522
Practice Address - Fax:323-773-8950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44656332B00000X
CAPHY 508013336C0003X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487683942Medicaid
CA5675420001Medicare NSC