Healthcare Provider Details

I. General information

NPI: 1588258859
Provider Name (Legal Business Name): 9NINE ONLINE STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 LONGVIEW DR
SACRAMENTO CA
95821-7103
US

IV. Provider business mailing address

PO BOX 661414
SACRAMENTO CA
95866-1414
US

V. Phone/Fax

Practice location:
  • Phone: 916-299-9942
  • Fax: 916-299-9941
Mailing address:
  • Phone: 916-299-9942
  • Fax: 916-299-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: SYED RAZA
Title or Position: CEO
Credential:
Phone: 916-299-9942