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?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82051763Medicaid
NM82051763Medicaid