Provider Demographics
NPI:1578020004
Name:MEDICAL SUPPLY DME LLC
Entity Type:Organization
Organization Name:MEDICAL SUPPLY DME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-865-2445
Mailing Address - Street 1:2400 PROMENADE BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-4001
Mailing Address - Country:US
Mailing Address - Phone:470-865-2445
Mailing Address - Fax:
Practice Address - Street 1:2400 PROMENADE BLVD APT 2
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-4001
Practice Address - Country:US
Practice Address - Phone:470-865-2445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies