Provider Demographics
NPI:1538124953
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 1302
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-1302
Mailing Address - Country:US
Mailing Address - Phone:512-332-0822
Mailing Address - Fax:866-576-3203
Practice Address - Street 1:123 OLD AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5128
Practice Address - Country:US
Practice Address - Phone:512-332-0822
Practice Address - Fax:512-332-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 225CA2500X
TX0040642332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143729501Medicaid
TX1437303-01Medicaid
TX519563OtherBLUE CROSS & BLUE SHIELD