Healthcare Provider Details

I. General information

NPI: 1780597583
Provider Name (Legal Business Name): MEDISOURCE SUPPLIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8056 LANGDALE ST
NEW HYDE PARK NY
11040-1512
US

IV. Provider business mailing address

8056 LANGDALE ST
NEW HYDE PARK NY
11040-1512
US

V. Phone/Fax

Practice location:
  • Phone: 803-232-3151
  • Fax:
Mailing address:
  • Phone: 803-232-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH ALLY
Title or Position: MANAGER
Credential:
Phone: 803-232-3151