Provider Demographics
NPI:1245922327
Name:LUCKY STRIKE MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:LUCKY STRIKE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EHIMWENMA
Authorized Official - Middle Name:K
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-291-4542
Mailing Address - Street 1:2258 W BROAD ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2263
Mailing Address - Country:US
Mailing Address - Phone:931-854-0686
Mailing Address - Fax:931-854-0692
Practice Address - Street 1:2258 W BROAD ST UNIT 1
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2263
Practice Address - Country:US
Practice Address - Phone:931-854-0686
Practice Address - Fax:931-854-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies