Provider Demographics
NPI:1669428124
Name:GRANDIFF MEDICAL SUPPLIES INC
Entity type:Organization
Organization Name:GRANDIFF MEDICAL SUPPLIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IMAOBONG
Authorized Official - Middle Name:NNSEWO
Authorized Official - Last Name:AKPAETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-388-0596
Mailing Address - Street 1:20 VITAL WAY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3446
Mailing Address - Country:US
Mailing Address - Phone:301-388-0596
Mailing Address - Fax:301-388-0597
Practice Address - Street 1:20 VITAL WAY
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-3446
Practice Address - Country:US
Practice Address - Phone:301-388-0596
Practice Address - Fax:301-388-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2253332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027061500Medicaid
VA009119175Medicaid
MD414364700Medicaid
MD10079260OtherAMERIGROUP
MD10079260OtherAMERIGROUP