Provider Demographics
NPI:1508802984
Name:MARIETTA MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:MARIETTA MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIVZENDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-432-7227
Mailing Address - Street 1:1730 AUSTELL RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4362
Mailing Address - Country:US
Mailing Address - Phone:770-432-7227
Mailing Address - Fax:
Practice Address - Street 1:1730 AUSTELL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4362
Practice Address - Country:US
Practice Address - Phone:770-432-7227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA116205332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies