1245265420 NPI number — METRO MEDICAL SUPPLY COMPANY LLC

Table of content: (NPI 1245265420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245265420 NPI number — METRO MEDICAL SUPPLY COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO MEDICAL SUPPLY COMPANY LLC
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:
Provider Other Organization Name Type Code:
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:
1245265420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16595
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39404-6595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-268-6939
Provider Business Mailing Address Fax Number:
601-268-6089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5268 OLD HIGHWAY 11
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-8379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-268-6939
Provider Business Practice Location Address Fax Number:
601-268-6089
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARDEN
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-268-6939

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  037-06632-1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00440960 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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