Provider Demographics
NPI:1619028917
Name:SOUTH SHREVE MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:SOUTH SHREVE MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MACEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:318-798-2648
Mailing Address - Street 1:PO BOX 52389
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2389
Mailing Address - Country:US
Mailing Address - Phone:318-798-2648
Mailing Address - Fax:318-798-3451
Practice Address - Street 1:8520 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5654
Practice Address - Country:US
Practice Address - Phone:318-798-2648
Practice Address - Fax:318-798-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies