Provider Demographics
NPI:1417179680
Name:TRINITY MEDICAL SUPPLY OF AIKEN,SC
Entity Type:Organization
Organization Name:TRINITY MEDICAL SUPPLY OF AIKEN,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:LARRAINE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-739-8987
Mailing Address - Street 1:4360 AUGUSTA RD # S-H189
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7491
Mailing Address - Country:US
Mailing Address - Phone:803-739-8987
Mailing Address - Fax:803-739-8907
Practice Address - Street 1:2316 SUNSET BLVD STE D
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4772
Practice Address - Country:US
Practice Address - Phone:803-739-8987
Practice Address - Fax:803-739-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3897260001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1822Medicaid
SCDE1822Medicaid