Provider Demographics
NPI:1245453984
Name:LIFE SUPPLY CORPORATIION
Entity type:Organization
Organization Name:LIFE SUPPLY CORPORATIION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-239-1002
Mailing Address - Street 1:280 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1244
Mailing Address - Country:US
Mailing Address - Phone:413-593-5555
Mailing Address - Fax:413-593-9530
Practice Address - Street 1:299 CAREW ST
Practice Address - Street 2:UNIT 134
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2301
Practice Address - Country:US
Practice Address - Phone:413-737-5555
Practice Address - Fax:413-214-7323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA0085173332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1151620003Medicare NSC