Provider Demographics
NPI:1871763185
Name:HIS GRACE MEDICAL SUPPLY AND MORE
Entity type:Organization
Organization Name:HIS GRACE MEDICAL SUPPLY AND MORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:O
Authorized Official - Last Name:ADENUGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-557-1668
Mailing Address - Street 1:PO BOX 153202
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-9202
Mailing Address - Country:US
Mailing Address - Phone:817-557-1668
Mailing Address - Fax:888-441-6930
Practice Address - Street 1:1901 SOUTHEAST PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-3605
Practice Address - Country:US
Practice Address - Phone:817-557-1668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0100320332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6063680001Medicare NSC