Provider Demographics
NPI:1508531377
Name:INTERSTATE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:INTERSTATE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HAIG
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:AVAKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:COF
Authorized Official - Phone:323-854-0023
Mailing Address - Street 1:430 SONORA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2743
Mailing Address - Country:US
Mailing Address - Phone:323-854-0023
Mailing Address - Fax:888-977-3393
Practice Address - Street 1:135 W BALL RD STE C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6023
Practice Address - Country:US
Practice Address - Phone:323-854-0023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-12
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies