Provider Demographics
NPI:1881787612
Name:VALLEY MEDICAL SUPPLY
Entity type:Organization
Organization Name:VALLEY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / FITTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED FITTER
Authorized Official - Phone:907-373-1014
Mailing Address - Street 1:546 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7019
Mailing Address - Country:US
Mailing Address - Phone:907-373-1014
Mailing Address - Fax:907-357-1424
Practice Address - Street 1:546 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7019
Practice Address - Country:US
Practice Address - Phone:907-373-1014
Practice Address - Fax:907-357-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK200280332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMS2280Medicaid
AKPO2280Medicaid
AK=========OtherINSURANCE (PRIVATE) I.D.
AK=========OtherINSURANCE (PRIVATE) I.D.