Provider Demographics
NPI:1629235213
Name:MINIMED DISTRIBUTION CORP.
Entity Type:Organization
Organization Name:MINIMED DISTRIBUTION CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL LEGAL SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-550-2017
Mailing Address - Street 1:18000 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1219
Mailing Address - Country:US
Mailing Address - Phone:800-646-4633
Mailing Address - Fax:
Practice Address - Street 1:1800 PYRAMID PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-1703
Practice Address - Country:US
Practice Address - Phone:800-646-4633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137682716Medicaid