Provider Demographics
NPI:1407908437
Name:TRISTATE MEDICAL SUPPLY, L.L.C.
Entity Type:Organization
Organization Name:TRISTATE MEDICAL SUPPLY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-886-9111
Mailing Address - Street 1:2253 THIRD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-5303
Mailing Address - Country:US
Mailing Address - Phone:334-886-9111
Mailing Address - Fax:334-886-9255
Practice Address - Street 1:2253 THIRD AVE STE 1
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5303
Practice Address - Country:US
Practice Address - Phone:334-886-9111
Practice Address - Fax:334-323-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL786332B00000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL106600Medicaid