Healthcare Provider Details

I. General information

NPI: 1316643133
Provider Name (Legal Business Name): TRITON SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 W 1725 N
LOGAN UT
84321-6783
US

IV. Provider business mailing address

258 S MAIN ST STE 210
LOGAN UT
84321-5768
US

V. Phone/Fax

Practice location:
  • Phone: 435-557-6687
  • Fax:
Mailing address:
  • Phone: 309-532-7226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: GREGORY CHAD MANGUM
Title or Position: OWNER
Credential:
Phone: 435-557-6687