MEDICARE: MEDICARE SUPPLY STORE

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

General Provider Information

NPI Number	:	1619111796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICARE SUPPLY STORE

Provider Business Mailing Address
First Line	:	3510 S KEYSTONE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-3610
Country	:	US
Telephone Number	:	317-215-5883
Fax Number	:	877-783-2054

Provider Business Practice Location Address
First Line	:	3510 S KEYSTONE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-3610
Country	:	US
Telephone Number	:	317-215-5883
Fax Number	:	877-783-2054

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. RYAN MICHAEL THOMAS
Credential	:	H.I.S.
Telephone Number	:	317-557-9090

Provider Enumeration Date	:	04/21/2009
Last Update Date	:	04/21/2009

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