MEDICARE: IDEAL MEDICAL 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1700024866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	4040 E BROAD ST
Second Line	:	SUITE 105
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4040 E BROAD ST
Second Line	:	SUITE 105
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1156
Country	:	US
Telephone Number	:	614-231-8877
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	LEONID KRUPOVLYANSKIY
Credential	:
Telephone Number	:	614-231-8877

Provider Enumeration Date	:	01/28/2009
Last Update Date	:	01/28/2009

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Directions to “IDEAL MEDICAL SUPPLY INC ” Practice Location

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