Provider Demographics
NPI:1962548917
Name:SIMON OGBEIDE D/B/A ORCHARD MEDICAL SUPPLY
Entity type:Organization
Organization Name:SIMON OGBEIDE D/B/A ORCHARD MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:E
Authorized Official - Last Name:OGBEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-602-1191
Mailing Address - Street 1:1106 N STATE HIGHWAY 360
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-2559
Mailing Address - Country:US
Mailing Address - Phone:972-602-1191
Mailing Address - Fax:972-602-7993
Practice Address - Street 1:1106 N STATE HIGHWAY 360
Practice Address - Street 2:SUITE 209
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-2559
Practice Address - Country:US
Practice Address - Phone:972-602-1191
Practice Address - Fax:972-602-7993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5698740001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1842627Medicaid
TX184262701Medicaid
TX184262702Medicaid
TX184262702Medicaid