Healthcare Provider Details

I. General information

NPI: 1487683942
Provider Name (Legal Business Name): MEDICAL SUPPLY DEPOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4846 FLORENCE AVE SUITE #B104
BELL CA
90201-4317
US

IV. Provider business mailing address

4846 FLORENCE AVE. SUITE #B104
BELL CA
90201-4399
US

V. Phone/Fax

Practice location:
  • Phone: 323-773-6522
  • Fax: 323-773-8950
Mailing address:
  • Phone: 323-773-6522
  • Fax: 323-773-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number44656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY 50801
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. NORBERTO PURUGGANAN BARROGA
Title or Position: PRESIDENT
Credential:
Phone: 323-773-6522