MEDICARE: ESSENTIAL MEDICAL SHOP, LLC

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	HMEL 11687	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HMEL 11687	OTHER	OH	STATE LICENSE

General Provider Information

NPI Number	:	1619356086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESSENTIAL MEDICAL SHOP, LLC

Provider Business Mailing Address
First Line	:	8385 N MAIN ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-1602
Country	:	US
Telephone Number	:	937-890-0449
Fax Number	:	937-890-0454

Provider Business Practice Location Address
First Line	:	8385 N MAIN ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-1602
Country	:	US
Telephone Number	:	937-890-0449
Fax Number	:	937-890-0454

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. YAKUB OLADELE
Credential	:
Telephone Number	:	937-890-0449

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	05/19/2015

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Directions to “ESSENTIAL MEDICAL SHOP, LLC ” Practice Location

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