Provider Demographics
NPI:1790012722
Name:MOUNTAIN PEAKS MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:MOUNTAIN PEAKS MEDICAL SUPPLIES, INC.
Other - Org Name:PRIME CARE MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-456-6192
Mailing Address - Street 1:16 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4995
Mailing Address - Country:US
Mailing Address - Phone:518-456-6192
Mailing Address - Fax:518-456-6193
Practice Address - Street 1:16 WALKER WAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4995
Practice Address - Country:US
Practice Address - Phone:518-456-6192
Practice Address - Fax:518-456-6193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03106145Medicaid