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General NPI Number Information
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NPI Number | 1619111796
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Entity Type | Organization
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Legal Business Name | MEDICARE SUPPLY STORE
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Dates
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Enumeration Date | 04/21/2009
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Last Update Date | 04/21/2009
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Provider Practice Location Address
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Address Line | 3510 S KEYSTONE AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-3610
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Country | US
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Telephone | 317-215-5883
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Fax | 877-783-2054
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Provider Business Mailing Address
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Address Line | 3510 S KEYSTONE AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-3610
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Country | US
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Telephone | 317-215-5883
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Fax | 877-783-2054
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. RYAN MICHAEL THOMAS
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Credential | H.I.S.
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Telephone | 317-557-9090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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