Healthcare Provider Details

I. General information

NPI: 1306863360
Provider Name (Legal Business Name): WESTERN MARYLAND MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 WINCHESTER RD SUITE 1A
LAVALE MD
21502-7688
US

IV. Provider business mailing address

12101 WINCHESTER RD SUITE 1A
LAVALE MD
21502-7688
US

V. Phone/Fax

Practice location:
  • Phone: 301-729-4280
  • Fax: 301-729-2944
Mailing address:
  • Phone: 301-729-4280
  • Fax: 301-729-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberR1119
License Number StateMD

VIII. Authorized Official

Name: MR. THOMAS T CHAN
Title or Position: CFO
Credential:
Phone: 301-790-8102