Provider Demographics
NPI:1619268810
Name:PATRICK E IGBOKWE
Entity Type:Organization
Organization Name:PATRICK E IGBOKWE
Other - Org Name:VICKSBURG MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:E
Authorized Official - Last Name:IGBOKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-636-3692
Mailing Address - Street 1:209 KENDRA DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-8986
Mailing Address - Country:US
Mailing Address - Phone:601-630-9300
Mailing Address - Fax:601-630-0133
Practice Address - Street 1:4798 HIGHWAY 61 S
Practice Address - Street 2:SUITE B
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-7125
Practice Address - Country:US
Practice Address - Phone:601-630-9300
Practice Address - Fax:601-630-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07659/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies