Provider Demographics
NPI:1679570105
Name:TRI STATE MEDICAL SUPPLY
Entity type:Organization
Organization Name:TRI STATE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:YUNGMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-337-2399
Mailing Address - Street 1:732 S SHOOP AVE
Mailing Address - Street 2:P.O. BOX 251
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1707
Mailing Address - Country:US
Mailing Address - Phone:419-337-2399
Mailing Address - Fax:419-337-5392
Practice Address - Street 1:732 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1707
Practice Address - Country:US
Practice Address - Phone:419-337-2399
Practice Address - Fax:419-337-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-0873800332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0469818Medicaid
OH0469818Medicaid