Provider Demographics
NPI:1780746768
Name:VILLAGE MEDICAL SUPPLY,LLC.
Entity type:Organization
Organization Name:VILLAGE MEDICAL SUPPLY,LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-652-7557
Mailing Address - Street 1:18 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-3085
Mailing Address - Country:US
Mailing Address - Phone:570-389-1161
Mailing Address - Fax:570-389-1163
Practice Address - Street 1:18 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-3085
Practice Address - Country:US
Practice Address - Phone:570-389-1161
Practice Address - Fax:570-389-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ332BC3200X332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012127610002Medicaid
PA529426OtherWELLCARE
NJ0018678Medicaid
PA2509434OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA39H56OtherCAPITAL BLUE CROSS
PA2509434OtherHIGHMARK BLUE CROSS BLUE SHIELD