Provider Demographics
NPI:1356980627
Name:LUCKY MEDICAL SUPPLY
Entity type:Organization
Organization Name:LUCKY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN PTR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCKO
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-741-1895
Mailing Address - Street 1:1580 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1916
Mailing Address - Country:US
Mailing Address - Phone:631-741-1895
Mailing Address - Fax:631-257-5866
Practice Address - Street 1:1580 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1916
Practice Address - Country:US
Practice Address - Phone:631-741-1895
Practice Address - Fax:631-257-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0321Medicaid