Healthcare Provider Details

I. General information

NPI: 1881787612
Provider Name (Legal Business Name): VALLEY MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 N MAIN ST
WASILLA AK
99654-7019
US

IV. Provider business mailing address

546 N MAIN ST
WASILLA AK
99654-7019
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-1014
  • Fax: 907-357-1424
Mailing address:
  • Phone: 907-373-1014
  • Fax: 907-357-1424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number200280
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMS2280
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
IdentifierPO2280
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MRS. GLENNA G. EDWARDS
Title or Position: OWNER / FITTER
Credential: CERTIFIED FITTER
Phone: 907-373-1014