Provider Demographics
NPI:1326015942
Name:MED-CO DIABETIC SUPPLIES, INC.
Entity Type:Organization
Organization Name:MED-CO DIABETIC SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALFONSO
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-661-1669
Mailing Address - Street 1:PO BOX 4143
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27115-4143
Mailing Address - Country:US
Mailing Address - Phone:336-661-1669
Mailing Address - Fax:336-661-1678
Practice Address - Street 1:4964 UNIVERSITY PKWY
Practice Address - Street 2:SUITE-107
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2809
Practice Address - Country:US
Practice Address - Phone:336-661-1669
Practice Address - Fax:336-661-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600424547332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703544Medicaid
NC7703544Medicaid