| Name | Value |
|---|---|
| PROVIDER TYPE | Suppliers |
| CLASSIFICATION | Durable Medical Equipment & Medical Supplies |
| AREA OF SPECIALIZATION | Parenteral & Enteral Nutrition |
| STATUS | Active |
| X12 CODE | 332BP3500X |
| INDIVIDUAL/NON | NON-INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255489 |
| EFFECTIVE DATE/TIME |
|