Organization
MEDSOURCE MEDICAL, LLC
Active
Other names
Ingram Medical
Organization subpart
No
Provider details
NPI number
Authorized official
ROBERT ROSE (COO)
(877) 577-7767
Entity
Organization
Contact information
Practice address
9883 S 500 W, SANDY, UT 84070-2561
(877) 577-7767
(801) 727-0092
Mailing address
9883 S 500 W, SANDY, UT 84070-2561
(877) 577-7767
(801) 727-0092
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
8119067-1714
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4612138
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
10/27/2011
Last updated
10/27/2011
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