Provider Demographics
NPI:1831192061
Name:LIFE SUPPLY CORP
Entity type:Organization
Organization Name:LIFE SUPPLY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-239-1002
Mailing Address - Street 1:280 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1244
Mailing Address - Country:US
Mailing Address - Phone:413-593-5555
Mailing Address - Fax:413-593-9530
Practice Address - Street 1:280 MOODY ST
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-1244
Practice Address - Country:US
Practice Address - Phone:413-593-5555
Practice Address - Fax:413-593-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003104429Medicaid
MA1537687Medicaid
MA378354OtherBC BS PROVIDER NUMBER
MA1537687Medicaid
MA1151620001Medicare PIN