Provider Demographics
NPI:1629133533
Name:KANAWHA MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:KANAWHA MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DYANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PERGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-330-5743
Mailing Address - Street 1:7009 FOREST HILL AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1607
Mailing Address - Country:US
Mailing Address - Phone:804-330-5743
Mailing Address - Fax:804-330-7149
Practice Address - Street 1:7009 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1607
Practice Address - Country:US
Practice Address - Phone:804-330-5743
Practice Address - Fax:804-330-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206008452332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment