Provider Demographics
NPI:1063571024
Name:OMEGA MEDICAL SUPPLY, LLC
Entity type:Organization
Organization Name:OMEGA MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADERONKE
Authorized Official - Middle Name:OLANREWAJU
Authorized Official - Last Name:MORDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-252-8413
Mailing Address - Street 1:3261 19TH ST. NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901
Mailing Address - Country:US
Mailing Address - Phone:507-252-8413
Mailing Address - Fax:
Practice Address - Street 1:3261 19TH ST. NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-252-8413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN331L1OMOtherBLUE CROSS
MN5263030001Medicare ID - Type Unspecified