Provider Demographics
NPI:1649383084
Name:HOME DELIVERY INCONTINENT SUPPLIES CO INC
Entity type:Organization
Organization Name:HOME DELIVERY INCONTINENT SUPPLIES CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-997-8771
Mailing Address - Street 1:9385 DIELMAN INDUSTRIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132
Mailing Address - Country:US
Mailing Address - Phone:314-997-8771
Mailing Address - Fax:314-997-0997
Practice Address - Street 1:9385 DIELMAN INDUSTRIAL DRIVE
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132
Practice Address - Country:US
Practice Address - Phone:314-997-8771
Practice Address - Fax:314-997-0997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOURNEY DPC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332B00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118720716Medicaid
MN535063800Medicaid
NJ8358702Medicaid
TX075269301Medicaid
TX015365201Medicaid
NC3408441Medicaid
VA010070724Medicaid
ID805526300Medicaid
MT0005603098Medicaid
NY02056215Medicaid
WI81866300Medicaid
IA0543678Medicaid
OH2167408Medicaid
IN100013540AMedicaid
MD117002300Medicaid
WA9028242Medicaid
TX079035401Medicaid
MO628652307Medicaid
CO98013006Medicaid
TX079035401Medicaid
NC3408441Medicaid
ID805526300Medicaid