Provider Demographics
NPI:1629068564
Name:PRIORITY MEDICAL SUPPLY INC.
Entity Type:Organization
Organization Name:PRIORITY MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-668-8723
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:STEVINSON
Mailing Address - State:CA
Mailing Address - Zip Code:95374-0008
Mailing Address - Country:US
Mailing Address - Phone:209-668-8723
Mailing Address - Fax:209-669-6135
Practice Address - Street 1:23763 W SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:STEVINSON
Practice Address - State:CA
Practice Address - Zip Code:95374-9998
Practice Address - Country:US
Practice Address - Phone:209-668-8723
Practice Address - Fax:209-669-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-23
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102914332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06950ZOtherBLUE SHIELD PROVIDER NUMB
CA=========OtherBLUE CROSS PROVIDER NUMBE
CA=========OtherTRICARE PROVIDER NUMBER
CADME03118FMedicaid
CADME03118FMedicaid