Provider Demographics
NPI:1750809836
Name:GRASSROOTS MEDICAL SUPPLY
Entity type:Organization
Organization Name:GRASSROOTS MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-421-5201
Mailing Address - Street 1:28 N. HIGHWAY 77
Mailing Address - Street 2:PMB 5105
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025
Mailing Address - Country:US
Mailing Address - Phone:928-421-5201
Mailing Address - Fax:
Practice Address - Street 1:NEC NAVAJO ROUTE 15 AND 60
Practice Address - Street 2:SUITE #2
Practice Address - City:WINLSOW
Practice Address - State:AZ
Practice Address - Zip Code:86047
Practice Address - Country:US
Practice Address - Phone:928-421-5201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies