Provider Demographics
NPI:1427274927
Name:PACIFIC COAST MEDICAL SUPPLY
Entity type:Organization
Organization Name:PACIFIC COAST MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:STUTZNEGGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-338-0349
Mailing Address - Street 1:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-0634
Mailing Address - Country:US
Mailing Address - Phone:503-338-0349
Mailing Address - Fax:
Practice Address - Street 1:2158 EXCHANGE ST
Practice Address - Street 2:STE 106
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3316
Practice Address - Country:US
Practice Address - Phone:503-338-0349
Practice Address - Fax:503-338-6998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X, 332BP3500X
ORNPC-0001961332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9046947Medicaid
OR500600821Medicaid
=========OtherTAX ID
OR500600821Medicaid