=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861880114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETIC SUPPLY DISTRIBUTORS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2015
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8688 SE OLEANDER ST
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-545-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8688 SE OLEANDER ST
-----------------------------------------------------
City | HOBE SOUND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33455-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-545-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. VIRGINIA A YORK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-545-1002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------