Provider Demographics
NPI:1720229859
Name:MAGNOLIAS POST-MASTECTOMY BOUTIQUE LLC
Entity Type:Organization
Organization Name:MAGNOLIAS POST-MASTECTOMY BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERRYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEDELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-831-3220
Mailing Address - Street 1:625 S STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2797
Mailing Address - Country:US
Mailing Address - Phone:317-831-3220
Mailing Address - Fax:317-831-3321
Practice Address - Street 1:625 S STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2797
Practice Address - Country:US
Practice Address - Phone:317-831-3220
Practice Address - Fax:317-831-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies