Healthcare Provider Details

I. General information

NPI: 1629927686
Provider Name (Legal Business Name): MEDEX SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16442 VANOWEN ST
LAKE BALBOA CA
91406-4729
US

IV. Provider business mailing address

16442 VANOWEN ST
LAKE BALBOA CA
91406-4729
US

V. Phone/Fax

Practice location:
  • Phone: 747-343-9575
  • Fax:
Mailing address:
  • Phone: 747-343-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHARIFKHON SIRODZHOV
Title or Position: PRESIDENT
Credential:
Phone: 747-343-9575