Provider Demographics
NPI:1508893009
Name:DIABETIC SUPPLY SOURCE, INC DBA DSS MEDICAL
Entity Type:Organization
Organization Name:DIABETIC SUPPLY SOURCE, INC DBA DSS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN SHUFORD
Authorized Official - Middle Name:V
Authorized Official - Last Name:SHUFORD
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:803-799-3505
Mailing Address - Street 1:2805 MILLWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205
Mailing Address - Country:US
Mailing Address - Phone:803-799-3505
Mailing Address - Fax:803-779-3505
Practice Address - Street 1:2805 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1298
Practice Address - Country:US
Practice Address - Phone:803-799-3505
Practice Address - Fax:803-779-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC002745332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0745Medicaid
SC=========OtherBLUE CROSS BLUE SHIELD
SCDM0745Medicaid