Provider Demographics
NPI: | 1841219979 |
---|---|
Name: | MEDICAL DEPOT INC |
Entity Type: | Organization |
Organization Name: | MEDICAL DEPOT INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RONALD |
Authorized Official - Middle Name: | LEWIS |
Authorized Official - Last Name: | HICKS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 505-326-2333 |
Mailing Address - Street 1: | 2010 EAST 19TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | FARMINGTON |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87401-2500 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-326-2333 |
Mailing Address - Fax: | 505-325-4443 |
Practice Address - Street 1: | 2010 EAST 19TH ST |
Practice Address - Street 2: | |
Practice Address - City: | FARMINGTON |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87401-2500 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-326-2333 |
Practice Address - Fax: | 505-325-4443 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-19 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | 82051763 | Medicaid | |
NM | 82051763 | Medicaid |