Provider Demographics
NPI:1477702801
Name:MERCY MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:MERCY MEDICAL SUPPLY LLC
Other - Org Name:MERCY MEDICAL SUPPLY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-506-9944
Mailing Address - Street 1:3584 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4171
Mailing Address - Country:US
Mailing Address - Phone:770-506-9944
Mailing Address - Fax:770-506-9921
Practice Address - Street 1:3584 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-506-9944
Practice Address - Fax:770-506-9921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL SUPPLY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-10
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA076482217AMedicaid
GA076482217AMedicaid