Provider Demographics
NPI:1821276973
Name:TIDE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:TIDE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ADEDAYO
Authorized Official - Last Name:OGUNGBIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-264-3000
Mailing Address - Street 1:2304 OAK LN
Mailing Address - Street 2:SUITE 13
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-8812
Mailing Address - Country:US
Mailing Address - Phone:972-264-3000
Mailing Address - Fax:972-264-3000
Practice Address - Street 1:2304 OAK LN
Practice Address - Street 2:SUITE 13
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-8812
Practice Address - Country:US
Practice Address - Phone:972-264-3000
Practice Address - Fax:972-264-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0089915332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187864701Medicaid
TX5763750001Medicare NSC