Provider Demographics
NPI:1194040196
Name:PROSPERITY MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:PROSPERITY MEDICAL SUPPLIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-736-5872
Mailing Address - Street 1:3031 SCOTSMAN RD STE 13
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1812
Mailing Address - Country:US
Mailing Address - Phone:803-736-5872
Mailing Address - Fax:
Practice Address - Street 1:3031 SCOTSMAN RD STE 13
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1812
Practice Address - Country:US
Practice Address - Phone:803-736-5872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20103991339055332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies