Provider Demographics
NPI:1558343889
Name:SPECIALTY MEDICAL SUPPLY OF MISSISSIPPI, INC.
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL SUPPLY OF MISSISSIPPI, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTON
Authorized Official - Middle Name:AVERY
Authorized Official - Last Name:BIGGS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-892-0360
Mailing Address - Street 1:103A E GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2777
Mailing Address - Country:US
Mailing Address - Phone:601-892-0360
Mailing Address - Fax:601-892-6055
Practice Address - Street 1:103A E GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2777
Practice Address - Country:US
Practice Address - Phone:601-892-0360
Practice Address - Fax:601-892-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440808Medicaid
MS00440808Medicaid