Provider Demographics
NPI:1619960663
Name:JQ MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:JQ MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-942-8582
Mailing Address - Street 1:PO BOX 711637
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1637
Mailing Address - Country:US
Mailing Address - Phone:801-942-8582
Mailing Address - Fax:801-942-8069
Practice Address - Street 1:6910 HIGHLAND DR
Practice Address - Street 2:SUITE 4
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3060
Practice Address - Country:US
Practice Address - Phone:801-942-8582
Practice Address - Fax:801-942-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTE42635332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3012912Medicaid
UT=========OtherTAX ID NUMBER