Provider Demographics
NPI:1609076702
Name:KILMICHAEL MEDICAL SUPPLIERS
Entity Type:Organization
Organization Name:KILMICHAEL MEDICAL SUPPLIERS
Other - Org Name:INHEALTH MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:662-283-1551
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:KILMICHAEL
Mailing Address - State:MS
Mailing Address - Zip Code:39747
Mailing Address - Country:US
Mailing Address - Phone:662-283-1551
Mailing Address - Fax:662-283-2332
Practice Address - Street 1:107 N FRONT STREET
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967
Practice Address - Country:US
Practice Address - Phone:662-283-1551
Practice Address - Fax:662-283-2332
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KILMICHAEL MEDICAL SUPPLIERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330316Medicaid
MS00440411Medicaid
MS1138070001Medicare NSC