Provider Demographics
NPI:1720278898
Name:GREMLIN SUPPLY CORPORATION
Entity Type:Organization
Organization Name:GREMLIN SUPPLY CORPORATION
Other - Org Name:GREMLIN MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-794-2085
Mailing Address - Street 1:15 SENECA AVE
Mailing Address - Street 2:PO BOX 155
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2555
Mailing Address - Country:US
Mailing Address - Phone:315-363-1236
Mailing Address - Fax:315-361-4884
Practice Address - Street 1:15 SENECA AVE
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2555
Practice Address - Country:US
Practice Address - Phone:315-363-1236
Practice Address - Fax:315-361-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5430100002Medicare NSC