MEDICARE: PINE ISLAND DIABETIC SUPPLY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205949625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE ISLAND DIABETIC SUPPLY INC

Provider Business Mailing Address
First Line	:	1400 COLONIAL BLVD
Second Line	:	SUITE 84
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1055
Country	:	US
Telephone Number	:	239-931-3131
Fax Number	:	239-931-3133

Provider Business Practice Location Address
First Line	:	1400 COLONIAL BLVD
Second Line	:	SUITE 84
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1055
Country	:	US
Telephone Number	:	239-931-3131
Fax Number	:	239-931-3133

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. PATRICIA ANN COBEY
Credential	:
Telephone Number	:	239-931-3131

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	08/07/2008

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