Provider Demographics
NPI:1750387114
Name:MAM MEDICAL SUPPLY INC.
Entity type:Organization
Organization Name:MAM MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-369-0510
Mailing Address - Street 1:2300 E DESERT INN RD
Mailing Address - Street 2:STE 2
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-3233
Mailing Address - Country:US
Mailing Address - Phone:702-369-0510
Mailing Address - Fax:702-369-9846
Practice Address - Street 1:2300 E DESERT INN RD
Practice Address - Street 2:STE 2
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-3233
Practice Address - Country:US
Practice Address - Phone:702-369-0510
Practice Address - Fax:702-369-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2000087.424332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVMP00124OtherNV. ST. BOARD OF PHARMACY
NV4373920001Medicare ID - Type Unspecified