Provider Demographics
NPI:1801356621
Name:DEEP SOUTH MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:DEEP SOUTH MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-927-3523
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SICILY ISLAND
Mailing Address - State:LA
Mailing Address - Zip Code:71368-0038
Mailing Address - Country:US
Mailing Address - Phone:318-389-5807
Mailing Address - Fax:318-389-5842
Practice Address - Street 1:311 CHISUM ST
Practice Address - Street 2:
Practice Address - City:SICILY ISLAND
Practice Address - State:LA
Practice Address - Zip Code:71368-4807
Practice Address - Country:US
Practice Address - Phone:318-389-5807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2207385Medicaid