Provider Demographics
NPI:1689656522
Name:MED-SOUTH, INC.
Entity Type:Organization
Organization Name:MED-SOUTH, INC.
Other - Org Name:FAMILY MEDICAL STORE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT OF CORPORATE DEVE
Authorized Official - Prefix:MR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:H
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-414-7525
Mailing Address - Street 1:406 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3400
Mailing Address - Country:US
Mailing Address - Phone:205-221-8200
Mailing Address - Fax:205-221-8270
Practice Address - Street 1:2330 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5905
Practice Address - Country:US
Practice Address - Phone:256-593-0677
Practice Address - Fax:256-593-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL188332B00000X
332BP3500X
AL900493332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0336010007Medicare NSC