Provider Demographics
NPI:1962589093
Name:EAGLE MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:EAGLE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRESKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-322-0928
Mailing Address - Street 1:11080 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:208-322-0928
Mailing Address - Fax:208-322-0931
Practice Address - Street 1:11080 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-322-0928
Practice Address - Fax:208-322-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID3963900001Medicare NSC