Provider Demographics
NPI:1245329721
Name:WESTSIDE MEDICAL SUPPLY
Entity type:Organization
Organization Name:WESTSIDE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IROEGBU
Authorized Official - Middle Name:BOBBY
Authorized Official - Last Name:ACHARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-974-8307
Mailing Address - Street 1:38713 TIERRA SUBIDA AVE STE 200-192
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4562
Mailing Address - Country:US
Mailing Address - Phone:661-974-8307
Mailing Address - Fax:661-974-8308
Practice Address - Street 1:44300 DIVISION ST STE B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-3512
Practice Address - Country:US
Practice Address - Phone:661-974-8307
Practice Address - Fax:661-974-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45517332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5967540001Medicare NSC