Provider Demographics
NPI:1932485406
Name:MAIN SOURCE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:MAIN SOURCE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMELI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-584-0127
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-0632
Mailing Address - Country:US
Mailing Address - Phone:714-584-0127
Mailing Address - Fax:
Practice Address - Street 1:3624 RANDEE WAY
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2830
Practice Address - Country:US
Practice Address - Phone:714-584-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA563007332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies