Provider Demographics
NPI:1205165800
Name:PRINCE GEORGE'S MEDICAL SUPPLIES
Entity type:Organization
Organization Name:PRINCE GEORGE'S MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARCIE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-534-0783
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20757-0514
Mailing Address - Country:US
Mailing Address - Phone:301-534-0783
Mailing Address - Fax:301-263-7221
Practice Address - Street 1:3605 GALLATIN ST
Practice Address - Street 2:SUITE 513
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3931
Practice Address - Country:US
Practice Address - Phone:301-534-0783
Practice Address - Fax:301-263-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13890384332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies