Provider Demographics
NPI:1609227123
Name:MEDICAL DEPOT LLC
Entity Type:Organization
Organization Name:MEDICAL DEPOT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RAYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-480-6509
Mailing Address - Street 1:4969 HWY 28
Mailing Address - Street 2:
Mailing Address - City:MIZE
Mailing Address - State:MS
Mailing Address - Zip Code:39116
Mailing Address - Country:US
Mailing Address - Phone:601-480-6509
Mailing Address - Fax:
Practice Address - Street 1:4969 HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:MIZE
Practice Address - State:MS
Practice Address - Zip Code:39116-5355
Practice Address - Country:US
Practice Address - Phone:601-480-6509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies