Provider Demographics
NPI:1639305709
Name:SUPERMOMMY'S SUPERSTORE, LLC
Entity Type:Organization
Organization Name:SUPERMOMMY'S SUPERSTORE, LLC
Other - Org Name:SUPERMOMMY'S SUPERSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-769-6693
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:RINEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40162-0268
Mailing Address - Country:US
Mailing Address - Phone:270-769-6693
Mailing Address - Fax:270-769-0911
Practice Address - Street 1:2411 RING RD
Practice Address - Street 2:SUITE 105
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5929
Practice Address - Country:US
Practice Address - Phone:270-769-6693
Practice Address - Fax:270-769-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies