Provider Demographics
NPI:1730372798
Name:TRICARE MEDICAL SUPPLIES, INC.
Entity type:Organization
Organization Name:TRICARE MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BABLOO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-575-4176
Mailing Address - Street 1:258 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2961
Mailing Address - Country:US
Mailing Address - Phone:615-575-4176
Mailing Address - Fax:615-452-9652
Practice Address - Street 1:258 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-2961
Practice Address - Country:US
Practice Address - Phone:615-575-4176
Practice Address - Fax:615-452-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6063070001Medicare NSC