Provider Demographics
NPI:1891027389
Name:MADISON MEDICAL SUPPLY
Entity Type:Organization
Organization Name:MADISON MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-281-9181
Mailing Address - Street 1:5313 50TH ST STE D6
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1838
Mailing Address - Country:US
Mailing Address - Phone:806-281-9181
Mailing Address - Fax:806-281-9176
Practice Address - Street 1:5313 50TH ST STE D6
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-1838
Practice Address - Country:US
Practice Address - Phone:806-281-9181
Practice Address - Fax:806-281-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6391240001Medicare NSC