Provider Demographics
NPI:1306022330
Name:ABAGAN MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:ABAGAN MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:EKONG
Authorized Official - Middle Name:A
Authorized Official - Last Name:UMOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-621-3090
Mailing Address - Street 1:2179 NORTHLAKE PKWY STE 20
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4106
Mailing Address - Country:US
Mailing Address - Phone:770-621-3090
Mailing Address - Fax:770-621-3091
Practice Address - Street 1:2179 NORTHLAKE PKWY STE 20
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4106
Practice Address - Country:US
Practice Address - Phone:770-621-3090
Practice Address - Fax:770-621-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08004787332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00201800OtherSTATE
GA6051790002OtherDME SUPPLIER NUMBER
GA00201800OtherSTATE