1366934093 NPI number — SOUTHERN MEDICAL SUPPLIES

Table of content: (NPI 1366934093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366934093 NPI number — SOUTHERN MEDICAL SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
SOUTHERN MEDICAL SUPPLIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERN DME
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366934093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 734129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-4129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-568-7775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3711 BRIARPARK DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-5242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-568-7775
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLA
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
713-568-7775

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1002145 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)