Provider Demographics
NPI:1902013899
Name:TRIANGLE DIABETIC SUPPLY
Entity Type:Organization
Organization Name:TRIANGLE DIABETIC SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-562-0007
Mailing Address - Street 1:1000 BRACKEN CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9358
Mailing Address - Country:US
Mailing Address - Phone:919-562-0007
Mailing Address - Fax:919-562-4670
Practice Address - Street 1:1000 BRACKEN CT
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9358
Practice Address - Country:US
Practice Address - Phone:919-562-0007
Practice Address - Fax:919-562-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
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
NC7703504Medicaid
NC4318180001Medicare NSC