Provider Demographics
NPI:1780826982
Name:BLUE SHIELD MEDICAL SUPPLY
Entity Type:Organization
Organization Name:BLUE SHIELD MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-838-2955
Mailing Address - Street 1:680 N 7TH ST # TTH
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1741
Mailing Address - Country:US
Mailing Address - Phone:409-838-2955
Mailing Address - Fax:
Practice Address - Street 1:680 N 7TH ST # TTH
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1741
Practice Address - Country:US
Practice Address - Phone:409-838-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies