Provider Demographics
NPI:1417151101
Name:B & G HARVEST MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:B & G HARVEST MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-687-6100
Mailing Address - Street 1:1801 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-3219
Mailing Address - Country:US
Mailing Address - Phone:940-687-6100
Mailing Address - Fax:940-687-6102
Practice Address - Street 1:1801 GRANT ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-3219
Practice Address - Country:US
Practice Address - Phone:940-687-6100
Practice Address - Fax:940-687-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5986710001Medicare NSC