Provider Demographics
NPI:1063669315
Name:MEDEQUIP HEALTH CORP
Entity Type:Organization
Organization Name:MEDEQUIP HEALTH CORP
Other - Org Name:MEDICAL CENTER WEST COMPDING LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-855-5502
Mailing Address - Street 1:465 N BELAIR RD
Mailing Address - Street 2:STE 1A2
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3188
Mailing Address - Country:US
Mailing Address - Phone:706-855-5502
Mailing Address - Fax:706-854-2425
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:1A2
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-855-5502
Practice Address - Fax:706-854-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0094843336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy