Provider Demographics
NPI:1508990375
Name:TABATHA TAYLOR
Entity Type:Organization
Organization Name:TABATHA TAYLOR
Other - Org Name:HOLLY MEDICAL SUPPLY COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-456-6713
Mailing Address - Street 1:3006 GRAY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-6684
Mailing Address - Country:US
Mailing Address - Phone:478-752-3660
Mailing Address - Fax:478-752-3622
Practice Address - Street 1:3006 GRAY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-6684
Practice Address - Country:US
Practice Address - Phone:478-752-3660
Practice Address - Fax:478-752-3622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013929050AMedicaid
GA51000005OtherBLUE CROSS & BLUE SHIELD
GA5903640001Medicare NSC