Provider Demographics
NPI:1629158910
Name:UNIVERSAL MEDICAL SUPPLIERS INC
Entity Type:Organization
Organization Name:UNIVERSAL MEDICAL SUPPLIERS INC
Other - Org Name:SULLIVAN CO MED CTR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HEINTZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-286-6711
Mailing Address - Street 1:PO BOX V
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:PA
Mailing Address - Zip Code:18626
Mailing Address - Country:US
Mailing Address - Phone:570-946-4116
Mailing Address - Fax:570-946-4322
Practice Address - Street 1:MAIN AND KING STS
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626
Practice Address - Country:US
Practice Address - Phone:570-946-4116
Practice Address - Fax:570-946-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413797L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1044153Medicaid
3951440OtherNABP
PA0395144OtherPACE