Provider Demographics
NPI:1700024866
Name:IDEAL MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:IDEAL MEDICAL SUPPLY INC
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUPOVLYANSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-231-8877
Mailing Address - Street 1:4040 E BROAD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4040 E BROAD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1156
Practice Address - Country:US
Practice Address - Phone:614-231-8877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5408580001Medicare NSC