Provider Demographics
NPI:1407333719
Name:GRACEFUL MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:GRACEFUL MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-315-8625
Mailing Address - Street 1:220 W BRANDON BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5100
Mailing Address - Country:US
Mailing Address - Phone:813-315-8625
Mailing Address - Fax:
Practice Address - Street 1:220 W BRANDON BLVD STE 206
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5100
Practice Address - Country:US
Practice Address - Phone:813-315-8625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies