Provider Demographics
NPI:1134302102
Name:INFINITY DIABETIC & MEDICAL SUPPLY
Entity Type:Organization
Organization Name:INFINITY DIABETIC & MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GEDDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-772-2555
Mailing Address - Street 1:PO BOX 3321
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3321
Mailing Address - Country:US
Mailing Address - Phone:803-772-2555
Mailing Address - Fax:803-772-2878
Practice Address - Street 1:1900 BROAD RIVER RD
Practice Address - Street 2:SUITE 17
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-7047
Practice Address - Country:US
Practice Address - Phone:803-772-2555
Practice Address - Fax:803-772-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2462Medicaid
SCDE2462Medicaid