# 1ST SOURCE MEDICAL SUPPLY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538610662
- **Authorized official:** VILLARD MCCOY (OWNER)
- **Authorized official phone:** (951) 350-4020

## Contact information

- **Practice address:** 1123 W 9TH ST, UPLAND, CA 91786-5704
- **Practice address phone:** (951) 350-4020
- **Practice address fax:** (951) 350-4012
- **Mailing address:** 1123 W 9TH ST, UPLAND, CA 91786-5704
- **Mailing address phone:** (951) 350-4020
- **Mailing address fax:** (951) 350-4012

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | Yes |

## Other

- **Enumeration date:** 10/24/2016
- **Last updated:** 10/24/2016