Provider Demographics
NPI:1336107572
Name:TRI-STATE MEDICAL SUPPLIES, INC
Entity Type:Organization
Organization Name:TRI-STATE MEDICAL SUPPLIES, INC
Other - Org Name:DIABETIC RESOURCE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:DIONE
Authorized Official - Last Name:TRAWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-671-3035
Mailing Address - Street 1:PO BOX 1032
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1032
Mailing Address - Country:US
Mailing Address - Phone:334-671-3035
Mailing Address - Fax:334-671-1195
Practice Address - Street 1:545 W MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1654
Practice Address - Country:US
Practice Address - Phone:334-671-3035
Practice Address - Fax:334-671-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009944675Medicaid
ALBCBSOther51516630
ALBCBSOther51516630