Provider Demographics
NPI:1922763150
Name:MASTECTOMY SHOPPE, LLC
Entity Type:Organization
Organization Name:MASTECTOMY SHOPPE, LLC
Other - Org Name:PINK RIBBON GALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-573-9596
Mailing Address - Street 1:9700 REDSTONE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5409
Mailing Address - Country:US
Mailing Address - Phone:803-548-8627
Mailing Address - Fax:803-548-8630
Practice Address - Street 1:9700 REDSTONE DR STE 200
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-5409
Practice Address - Country:US
Practice Address - Phone:803-548-8627
Practice Address - Fax:803-548-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies