Provider Demographics
NPI:1710022322
Name:DIABETIC SUPPLY SOURCE, INC
Entity Type:Organization
Organization Name:DIABETIC SUPPLY SOURCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-799-3505
Mailing Address - Street 1:PO BOX 25534
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-5534
Mailing Address - Country:US
Mailing Address - Phone:803-799-3505
Mailing Address - Fax:803-256-1083
Practice Address - Street 1:2805 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1298
Practice Address - Country:US
Practice Address - Phone:803-799-3505
Practice Address - Fax:803-256-1083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50-0086193336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4226292OtherNCPDP
SC786194Medicaid
SC50-008619OtherPHARMACY PERMIT NUMBER
SC4226292OtherNCPDP