Provider Demographics
NPI:1831287986
Name:THE OXYGEN STORE, INC
Entity Type:Organization
Organization Name:THE OXYGEN STORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-290-1330
Mailing Address - Street 1:115 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1419
Mailing Address - Country:US
Mailing Address - Phone:706-290-1330
Mailing Address - Fax:706-290-1332
Practice Address - Street 1:115 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:706-290-1330
Practice Address - Fax:706-290-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00953345AMedicaid
GA00953345AMedicaid