Provider Demographics
NPI:1508179326
Name:POMONA MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:POMONA MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HELLIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-623-4378
Mailing Address - Street 1:733 E HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5627
Mailing Address - Country:US
Mailing Address - Phone:909-623-4378
Mailing Address - Fax:909-622-2375
Practice Address - Street 1:733 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5627
Practice Address - Country:US
Practice Address - Phone:909-623-4378
Practice Address - Fax:909-622-2375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31459ZMedicaid