MEDICARE: WALLA WALLA HOMEMEDICAL 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	601013167	WA

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942203781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLA WALLA HOMEMEDICAL INC

Provider Business Mailing Address
First Line	:	329 S 2ND AVE
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-3034
Country	:	US
Telephone Number	:	509-525-1066
Fax Number	:	509-522-2361

Provider Business Practice Location Address
First Line	:	329 S 2ND AVE
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-3034
Country	:	US
Telephone Number	:	509-525-1066
Fax Number	:	509-522-2361

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	JAY BUCKLEY
Credential	:
Telephone Number	:	509-525-1066

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	12/21/2012

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