Provider Demographics
NPI:1295790061
Name:FAYETTE MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:FAYETTE MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-968-6680
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-0939
Mailing Address - Country:US
Mailing Address - Phone:979-968-6680
Mailing Address - Fax:866-272-1911
Practice Address - Street 1:362 E TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2619
Practice Address - Country:US
Practice Address - Phone:979-968-6680
Practice Address - Fax:979-404-6082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225CA2500X, 332B00000X
TX0031424332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology SupplierGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086664201Medicaid
TX506466OtherBLUE CROSS & BLUE SHIELD
TX0395780001Medicare NSC