Provider Demographics
NPI:1932568946
Name:INTERIOR MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:INTERIOR MEDICAL SUPPLY LLC
Other - Org Name:INTERIOR MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:INGRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-457-8486
Mailing Address - Street 1:915 30TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7577
Mailing Address - Country:US
Mailing Address - Phone:907-457-8486
Mailing Address - Fax:
Practice Address - Street 1:907 E DOWLING RD
Practice Address - Street 2:STE 25
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1426
Practice Address - Country:US
Practice Address - Phone:907-561-8486
Practice Address - Fax:907-561-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK297766332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK297766OtherSTATE BUSINESS LICENSE
AK1261190002Medicare NSC