MEDICARE: PAYLESS MEDICAL SUPPLIES, 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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7504290001	OTHER	NC	MEDICARE PTAN

General Provider Information

NPI Number	:	1891179586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAYLESS MEDICAL SUPPLIES, LLC

Provider Business Mailing Address
First Line	:	13910 LYNMAR BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3123
Country	:	US
Telephone Number	:	866-533-0772
Fax Number	:	866-629-5786

Provider Business Practice Location Address
First Line	:	108 N FAYETTEVILLE ST STE J
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-3203
Country	:	US
Telephone Number	:	866-533-0772
Fax Number	:	866-629-5786

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. JON ROBICHAUD
Credential	:
Telephone Number	:	506-871-9455

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	08/24/2022

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