Provider Demographics
NPI:1548258858
Name:ABBA MEDICAL SUPPLY
Entity type:Organization
Organization Name:ABBA MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-778-1698
Mailing Address - Street 1:72 PORTSMOUTH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2566
Mailing Address - Country:US
Mailing Address - Phone:603-778-1698
Mailing Address - Fax:603-772-5885
Practice Address - Street 1:72 PORTSMOUTH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2566
Practice Address - Country:US
Practice Address - Phone:603-778-1698
Practice Address - Fax:603-772-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4224332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1203280YONHIOtherBLUE CROSS BLUE SHIELD
020463317OtherTRICARE
NH30008709Medicaid
292170OtherHEALTHSOURCE
PO020021OtherCHAMPA AVA
=========OtherCIGNA
292170OtherHEALTHSOURCE