Provider Demographics
NPI:1679650907
Name:LIGHTHOUSE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL - PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:O'DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-575-1401
Mailing Address - Street 1:245 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4063
Mailing Address - Country:US
Mailing Address - Phone:866-633-0005
Mailing Address - Fax:860-343-8111
Practice Address - Street 1:245 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4063
Practice Address - Country:US
Practice Address - Phone:866-633-0005
Practice Address - Fax:860-343-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
4614520001Medicare NSC