Provider Demographics
NPI:1548208036
Name:FIVE STAR MEDICAL SUPPLY INCORPORATED
Entity Type:Organization
Organization Name:FIVE STAR MEDICAL SUPPLY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:IJOMA
Authorized Official - Last Name:EGEOLU
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:210-731-0500
Mailing Address - Street 1:1123 BABCOCK RD
Mailing Address - Street 2:STE. C
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-6917
Mailing Address - Country:US
Mailing Address - Phone:210-731-0500
Mailing Address - Fax:210-736-3740
Practice Address - Street 1:1123 BABCOCK RD
Practice Address - Street 2:STE. C
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6917
Practice Address - Country:US
Practice Address - Phone:210-731-0500
Practice Address - Fax:210-736-3740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0088709332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183205701Medicaid
TX5737700001Medicare NSC