Provider Demographics
NPI:1780866624
Name:UDUAK EDWARDS FSH MEDICAL SUPPLIES
Entity type:Organization
Organization Name:UDUAK EDWARDS FSH MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:UDUAK
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-329-6593
Mailing Address - Street 1:317 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3575
Mailing Address - Country:US
Mailing Address - Phone:972-329-6593
Mailing Address - Fax:972-285-9820
Practice Address - Street 1:317 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3575
Practice Address - Country:US
Practice Address - Phone:972-329-6593
Practice Address - Fax:972-285-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4569730001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154983401Medicaid
TX154983402Medicaid
TX154983401Medicaid