Provider Demographics
NPI:1477556389
Name:COUNTRY SOUTH INC
Entity Type:Organization
Organization Name:COUNTRY SOUTH INC
Other - Org Name:DIABETIC SUPPLY OF AMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FISCINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-514-1156
Mailing Address - Street 1:PO BOX 110189
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-0104
Mailing Address - Country:US
Mailing Address - Phone:239-514-1156
Mailing Address - Fax:239-514-1159
Practice Address - Street 1:5567 TAYLOR RD
Practice Address - Street 2:STE 8
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-1880
Practice Address - Country:US
Practice Address - Phone:239-514-1156
Practice Address - Fax:239-514-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL943257332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL951568200Medicaid
FL951568200Medicaid