Provider Demographics
NPI:1841217577
Name:EASTERN MEDICAL SUPPLY
Entity Type:Organization
Organization Name:EASTERN MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARDALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-863-3450
Mailing Address - Street 1:6758 NW 72 AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-863-3450
Mailing Address - Fax:305-863-3451
Practice Address - Street 1:6758 NW 72 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-863-3450
Practice Address - Fax:305-863-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1312728332B00000X
FL3204254332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5517090001Medicare ID - Type Unspecified