MEDICARE: DIABETES SUPPLY PROGRAM,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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457370587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETES SUPPLY PROGRAM,INC.

Provider Business Mailing Address
First Line	:	5121 BOWDEN RD
Second Line	:	SUITE 309
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5961
Country	:	US
Telephone Number	:	904-367-1694
Fax Number	:	904-367-8299

Provider Business Practice Location Address
First Line	:	5121 BOWDEN RD
Second Line	:	SUITE 309
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5961
Country	:	US
Telephone Number	:	904-367-1694
Fax Number	:	904-367-8299

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. SETH R WHITE
Credential	:
Telephone Number	:	904-367-1694

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	09/15/2008

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