Provider Demographics
NPI:1073676995
Name:SECURE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:SECURE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOPE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-918-1882
Mailing Address - Street 1:977 S MAIN ST
Mailing Address - Street 2:#5E
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:770-918-1882
Mailing Address - Fax:770-918-1872
Practice Address - Street 1:977 S MAIN ST
Practice Address - Street 2:#5E
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:770-918-1882
Practice Address - Fax:770-918-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5448000001Medicare ID - Type Unspecified