Provider Demographics
NPI:1720117203
Name:HARBOR MEDICAL SUPPLY
Entity Type:Organization
Organization Name:HARBOR MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERZHERITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-336-9269
Mailing Address - Street 1:2917 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2910
Mailing Address - Country:US
Mailing Address - Phone:916-372-8766
Mailing Address - Fax:916-372-1750
Practice Address - Street 1:2917 W CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2910
Practice Address - Country:US
Practice Address - Phone:916-372-8766
Practice Address - Fax:916-372-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADME0218OF332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02180FMedicaid
CA1090880001Medicare NSC