Provider Demographics
NPI:1992845739
Name:NORTHWEST DIABETIC SUPPLY
Entity Type:Organization
Organization Name:NORTHWEST DIABETIC SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-239-4590
Mailing Address - Street 1:24102 S BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-8958
Mailing Address - Country:US
Mailing Address - Phone:509-239-4590
Mailing Address - Fax:509-239-4591
Practice Address - Street 1:24102 S BOSTON RD
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-8958
Practice Address - Country:US
Practice Address - Phone:509-239-4590
Practice Address - Fax:509-239-4591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherEIN
WA5868320001Medicare NSC