Provider Demographics
NPI:1285631614
Name:AT HOME MEDICAL SUPPLY OF HOLLY SPRINGS, LLC
Entity Type:Organization
Organization Name:AT HOME MEDICAL SUPPLY OF HOLLY SPRINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-748-9148
Mailing Address - Street 1:621 HIGHWAY 7 S
Mailing Address - Street 2:BOX C
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-9108
Mailing Address - Country:US
Mailing Address - Phone:800-748-9148
Mailing Address - Fax:662-252-2320
Practice Address - Street 1:621 HIGHWAY 7 S
Practice Address - Street 2:BOX C
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-9108
Practice Address - Country:US
Practice Address - Phone:800-748-9148
Practice Address - Fax:662-252-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03810/11.1332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440674Medicaid
MS00440674Medicaid