Provider Demographics
NPI:1699702126
Name:MEDSTAR MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:MEDSTAR MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-842-6001
Mailing Address - Street 1:166 THOMPSON DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1644
Mailing Address - Country:US
Mailing Address - Phone:304-842-6001
Mailing Address - Fax:304-842-6111
Practice Address - Street 1:166 THOMPSON DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1644
Practice Address - Country:US
Practice Address - Phone:304-842-6001
Practice Address - Fax:304-842-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332BD1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherEIN NUMBER