Provider Demographics
NPI:1063045409
Name:YOUR MEDICAL SUPPLY CO, LLC
Entity Type:Organization
Organization Name:YOUR MEDICAL SUPPLY CO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JADA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-265-2055
Mailing Address - Street 1:19G E LINCOLN RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-8757
Mailing Address - Country:US
Mailing Address - Phone:601-265-2055
Mailing Address - Fax:
Practice Address - Street 1:19G E LINCOLN RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-8757
Practice Address - Country:US
Practice Address - Phone:601-265-2055
Practice Address - Fax:601-265-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies