Provider Demographics
NPI:1780858175
Name:MALAD MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:MALAD MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-484-3339
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-0247
Mailing Address - Country:US
Mailing Address - Phone:208-484-3339
Mailing Address - Fax:
Practice Address - Street 1:136 N 70 E
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1208
Practice Address - Country:US
Practice Address - Phone:208-484-3339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6283820001Medicare NSC