Provider Demographics
NPI:1114914678
Name:MOUNTAIN MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-865-4096
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256
Mailing Address - Country:US
Mailing Address - Phone:276-865-4096
Mailing Address - Fax:276-865-4098
Practice Address - Street 1:521 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYSI
Practice Address - State:VA
Practice Address - Zip Code:24256
Practice Address - Country:US
Practice Address - Phone:276-865-4096
Practice Address - Fax:276-865-4098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206009028332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0441920001Medicare ID - Type Unspecified