Provider Demographics
NPI:1154561769
Name:GRANDIFF MEDICAL SUPPLIES INC
Entity type:Organization
Organization Name:GRANDIFF MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMAOBONG
Authorized Official - Middle Name:
Authorized Official - Last Name:AKPAETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-9100
Mailing Address - Street 1:11631 NEBEL ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2503
Mailing Address - Country:US
Mailing Address - Phone:301-816-9100
Mailing Address - Fax:301-816-0003
Practice Address - Street 1:11631 NEBEL ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2503
Practice Address - Country:US
Practice Address - Phone:301-816-9100
Practice Address - Fax:301-816-0003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANDIFF MEDICAL SUPPLIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2253332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154561769Medicaid
MD419181100Medicaid
5568980002Medicare NSC