Provider Demographics
NPI:1538680160
Name:LEGACY MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:LEGACY MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOVELYN MARIE
Authorized Official - Middle Name:PEDRO
Authorized Official - Last Name:RAMENTO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:808-330-9508
Mailing Address - Street 1:98-138 HILA PL # PA05
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3201
Mailing Address - Country:US
Mailing Address - Phone:808-312-1632
Mailing Address - Fax:808-312-4205
Practice Address - Street 1:98-138 HILA PL # PA05
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3201
Practice Address - Country:US
Practice Address - Phone:808-312-1632
Practice Address - Fax:808-312-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies