Healthcare Provider Details

I. General information

NPI: 1689968042
Provider Name (Legal Business Name): EASTSIDE MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 E PALMDALE BLVD SUITE 124
PALMDALE CA
93550-4930
US

IV. Provider business mailing address

2720 E PALMDALE BLVD SUITE 124
PALMDALE CA
93550-4930
US

V. Phone/Fax

Practice location:
  • Phone: 661-272-0004
  • Fax:
Mailing address:
  • Phone: 661-272-0004
  • 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: LIANA GRIGORYAN
Title or Position: CEO
Credential:
Phone: 661-272-0004