Provider Demographics
NPI:1902037088
Name:MERCY DIABETIC SUPPLY INC.
Entity Type:Organization
Organization Name:MERCY DIABETIC SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EUNJA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-242-5030
Mailing Address - Street 1:3140 W BRITTON RD
Mailing Address - Street 2:SUITE #201
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2039
Mailing Address - Country:US
Mailing Address - Phone:405-242-5030
Mailing Address - Fax:405-242-5309
Practice Address - Street 1:3140 W BRITTON RD
Practice Address - Street 2:SUITE #201
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2039
Practice Address - Country:US
Practice Address - Phone:405-242-5030
Practice Address - Fax:405-242-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK542611332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200286530AMedicaid
6372320001Medicare NSC