Provider Demographics
NPI:1215171764
Name:WVA DIABETIC SUPPLIES LLC
Entity type:Organization
Organization Name:WVA DIABETIC SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-592-3340
Mailing Address - Street 1:409 S PIKE ST
Mailing Address - Street 2:
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1125
Mailing Address - Country:US
Mailing Address - Phone:304-592-1870
Mailing Address - Fax:304-592-1890
Practice Address - Street 1:409 S PIKE ST
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1125
Practice Address - Country:US
Practice Address - Phone:304-592-1870
Practice Address - Fax:304-592-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2223-3336335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015096Medicaid
WV6258090001Medicare NSC