MEDICARE: GREEN MOUNTAIN MEDICAL STORE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1235612169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN MOUNTAIN MEDICAL STORE LLC

Provider Business Mailing Address
First Line	:	46 FOX RUN RD
Second Line	:
City	:	ESSEX JUNCTION
State	:	VT
Zip	:	05452-2653
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 FOX RUN RD
Second Line	:
City	:	ESSEX JUNCTION
State	:	VT
Zip	:	05452-2653
Country	:	US
Telephone Number	:	802-598-2697
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MITALI R ASHER
Credential	:
Telephone Number	:	802-598-2697

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	09/06/2018

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