Provider Demographics
NPI:1467849059
Name:SMOKY RIDGE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:SMOKY RIDGE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-777-4721
Mailing Address - Street 1:1195 SAINT MATTHEWS RD
Mailing Address - Street 2:NUM 211
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3417
Mailing Address - Country:US
Mailing Address - Phone:912-777-4721
Mailing Address - Fax:
Practice Address - Street 1:1195 SAINT MATTHEWS RD
Practice Address - Street 2:NUM 211
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3417
Practice Address - Country:US
Practice Address - Phone:912-777-4721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies