Provider Demographics
NPI:1174708705
Name:EMBRY MEDICAL SUPPLY
Entity type:Organization
Organization Name:EMBRY MEDICAL SUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:EMBRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-879-9287
Mailing Address - Street 1:10 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:CANEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42721-9176
Mailing Address - Country:US
Mailing Address - Phone:270-879-9287
Mailing Address - Fax:270-879-3405
Practice Address - Street 1:10 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:CANEYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42721-9176
Practice Address - Country:US
Practice Address - Phone:270-879-9287
Practice Address - Fax:270-879-3405
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMBRY WELDING SUPPLY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-02
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1051288OtherPASSPORT
KY90010430Medicaid
KY2433002000OtherPASSPORT ADVANTAGE
KY45901287OtherMEDICIAD EPSDT
KY000000070263OtherBC
KY2433002000OtherPASSPORT ADVANTAGE