Provider Demographics
NPI:1548204753
Name:TECH MED SUPPLY
Entity Type:Organization
Organization Name:TECH MED SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:601-932-0673
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0636
Mailing Address - Country:US
Mailing Address - Phone:601-932-0673
Mailing Address - Fax:601-420-5299
Practice Address - Street 1:3900 LAKELAND DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8852
Practice Address - Country:US
Practice Address - Phone:601-932-0673
Practice Address - Fax:601-420-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06345/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02971738Medicaid
MS4217300001Medicare NSC