Provider Demographics
NPI:1508261926
Name:ALLY MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ALLY MEDICAL SUPPLY
Other - Org Name:DIABETIC SHOES INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LIBAN
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-208-0282
Mailing Address - Street 1:6238 LYNDALE AVE SOUTH
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:612-208-0282
Mailing Address - Fax:612-345-5582
Practice Address - Street 1:6238 LYNDALE AVE SOUTH
Practice Address - Street 2:SUITE # 2
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423
Practice Address - Country:US
Practice Address - Phone:612-208-0282
Practice Address - Fax:612-345-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7472270001Medicare PIN
MN6480820001Medicare PIN