Provider Demographics
NPI:1063535599
Name:MILLENNIUM MEDICAL SUPPLY
Entity type:Organization
Organization Name:MILLENNIUM MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-348-0652
Mailing Address - Street 1:1741 S. 20TH AVE.
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4012
Mailing Address - Country:US
Mailing Address - Phone:928-348-0652
Mailing Address - Fax:928-348-0695
Practice Address - Street 1:1741 S. 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4012
Practice Address - Country:US
Practice Address - Phone:928-348-0652
Practice Address - Fax:928-348-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4700410001Medicare NSC