Provider Demographics
NPI:1497828636
Name:MEMORIAL MEDICAL SUPPLY
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-556-6565
Mailing Address - Street 1:1009B DAIRY ASHFORD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-4602
Mailing Address - Country:US
Mailing Address - Phone:281-556-6565
Mailing Address - Fax:281-556-6566
Practice Address - Street 1:1009B DAIRY ASHFORD ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-4602
Practice Address - Country:US
Practice Address - Phone:281-556-6565
Practice Address - Fax:281-556-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179681501Medicaid
TX5475740001Medicare ID - Type Unspecified