Provider Demographics
NPI:1831414218
Name:GREAT SIMOD MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:GREAT SIMOD MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:OGINNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-977-0512
Mailing Address - Street 1:PO BOX 214913
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-0913
Mailing Address - Country:US
Mailing Address - Phone:916-977-0512
Mailing Address - Fax:916-977-0505
Practice Address - Street 1:3400 WATT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-3602
Practice Address - Country:US
Practice Address - Phone:916-977-0512
Practice Address - Fax:916-977-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52595332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies