1700078136 NPI number — TYSON MEDICAL SUPPLIES INC

Table of content: (NPI 1700078136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700078136 NPI number — TYSON MEDICAL SUPPLIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYSON MEDICAL SUPPLIES INC
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:
1700078136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 OLD MILL RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-5362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-284-9200
Provider Business Mailing Address Fax Number:
864-284-9209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 OLD MILL RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-5362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-284-9200
Provider Business Practice Location Address Fax Number:
864-284-9209
Provider Enumeration Date:
08/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEAVER
Authorized Official First Name:
COREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
864-284-9200

Provider Taxonomy Codes

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

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

  • Identifier: DE2675 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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