Provider Demographics
NPI:1467568337
Name:TWIN STATES VITAL CARE, INC.
Entity Type:Organization
Organization Name:TWIN STATES VITAL CARE, INC.
Other - Org Name:MEDICINE MART VITAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STERLING
Authorized Official - Middle Name:GRADY
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-653-6169
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:218B S MAIN ST
Practice Address - Street 2:
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463-1904
Practice Address - Country:US
Practice Address - Phone:910-653-6169
Practice Address - Fax:910-653-6078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2627-IR332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6800472Medicaid
NC7703531Medicaid
SC7N7828Medicaid
NC0245837Medicaid
SCDE2065Medicaid
4275110001Medicare NSC
NC2779490Medicare ID - Type UnspecifiedPART B