Provider Demographics
NPI:1972044766
Name:MOUNTAIN WEST MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHUMWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-459-4407
Mailing Address - Street 1:301 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3831
Mailing Address - Country:US
Mailing Address - Phone:435-678-2239
Mailing Address - Fax:435-678-3793
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3831
Practice Address - Country:US
Practice Address - Phone:435-678-2239
Practice Address - Fax:435-678-3793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies