Provider Demographics
NPI:1457370587
Name:DIABETES SUPPLY PROGRAM,INC.
Entity Type:Organization
Organization Name:DIABETES SUPPLY PROGRAM,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-367-1694
Mailing Address - Street 1:5121 BOWDEN RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5961
Mailing Address - Country:US
Mailing Address - Phone:904-367-1694
Mailing Address - Fax:904-367-8299
Practice Address - Street 1:5121 BOWDEN RD
Practice Address - Street 2:SUITE 309
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5961
Practice Address - Country:US
Practice Address - Phone:904-367-1694
Practice Address - Fax:904-367-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116778797AMedicaid
FL032429900Medicaid
5731890001Medicare NSC