Healthcare Provider Details

I. General information

NPI: 1376113068
Provider Name (Legal Business Name): ST JUDE MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 MERTON DR STE 130
RALEIGH NC
27609-6636
US

IV. Provider business mailing address

3900 MERTON DR STE 130
RALEIGH NC
27609-6636
US

V. Phone/Fax

Practice location:
  • Phone: 984-242-4742
  • Fax:
Mailing address:
  • Phone: 984-242-4742
  • Fax:

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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JUDE NWAODU
Title or Position: PRESIDENT
Credential:
Phone: 919-618-8033