Provider Demographics
NPI:1740354521
Name:SHALEM MEDICAL SUPPLIES INC
Entity type:Organization
Organization Name:SHALEM MEDICAL SUPPLIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-222-9263
Mailing Address - Street 1:PO BOX 850436
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0436
Mailing Address - Country:US
Mailing Address - Phone:972-222-9263
Mailing Address - Fax:972-226-6096
Practice Address - Street 1:2611 N BELT LINE RD
Practice Address - Street 2:113
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-9301
Practice Address - Country:US
Practice Address - Phone:972-222-9263
Practice Address - Fax:972-226-6096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0066969332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1551566-01Medicaid
TX1551566-02Medicaid
TX531465OtherBLUECROSS BLUESHIELD TX
TX531465OtherBLUECROSS BLUESHIELD TX