Healthcare Provider Details

I. General information

NPI: 1619111796
Provider Name (Legal Business Name): MEDICARE SUPPLY STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 S KEYSTONE AVE
INDIANAPOLIS IN
46227-3610
US

IV. Provider business mailing address

3510 S KEYSTONE AVE
INDIANAPOLIS IN
46227-3610
US

V. Phone/Fax

Practice location:
  • Phone: 317-215-5883
  • Fax: 877-783-2054
Mailing address:
  • Phone: 317-215-5883
  • Fax: 877-783-2054

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: MR. RYAN MICHAEL THOMAS
Title or Position: VICE PRESIDENT
Credential: H.I.S.
Phone: 317-557-9090