Provider Demographics
NPI:1033627948
Name:GRACE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:GRACE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-823-0325
Mailing Address - Street 1:655 LAKE HARBOUR DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4360
Mailing Address - Country:US
Mailing Address - Phone:769-823-0325
Mailing Address - Fax:
Practice Address - Street 1:655 LAKE HARBOUR DR STE 1100
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4360
Practice Address - Country:US
Practice Address - Phone:769-823-0325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1117383332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies