Provider Demographics
NPI:1528594348
Name:MEDIWEST SPECIALTY DISTRIBUTION LLC
Entity Type:Organization
Organization Name:MEDIWEST SPECIALTY DISTRIBUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IBSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-376-4665
Mailing Address - Street 1:PO BOX 3795
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HORMIGUEROS OFFICE PARK PETROWEST PLAZA
Practice Address - Street 2:CARR 345 KM 1.5
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660
Practice Address - Country:US
Practice Address - Phone:787-248-4144
Practice Address - Fax:787-966-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies