Provider Demographics
NPI:1134106578
Name:KANAWHA MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:KANAWHA MEDICAL SUPPLY INC
Other - Org Name:KANAWHA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DYANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PERGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-352-7671
Mailing Address - Street 1:7009 FOREST HILL AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1607
Mailing Address - Country:US
Mailing Address - Phone:804-330-5743
Mailing Address - Fax:804-330-7149
Practice Address - Street 1:7009 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1607
Practice Address - Country:US
Practice Address - Phone:804-330-5937
Practice Address - Fax:804-330-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
231350OtherANTHEM BCBS
VA0087009400Medicaid
VA0102164867Medicaid
VA1437165057Medicaid
VA009132287Medicaid
VA0102224273Medicaid
VA0087720295Medicaid
VA0102181440Medicaid
VA0102181952Medicaid
VA1437165057Medicaid