Provider Demographics
NPI:1205802899
Name:GOODWIN STREET MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:GOODWIN STREET MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:HEROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-541-1825
Mailing Address - Street 1:406 W GOODWIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-3737
Mailing Address - Country:US
Mailing Address - Phone:928-541-1825
Mailing Address - Fax:928-541-1823
Practice Address - Street 1:406 W GOODWIN ST
Practice Address - Street 2:STE 1
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-3737
Practice Address - Country:US
Practice Address - Phone:928-541-1825
Practice Address - Fax:928-541-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20002621332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5131890001Medicare NSC