Provider Demographics
NPI:1891878195
Name:SIMPSON COUNTY MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:SIMPSON COUNTY MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-849-9182
Mailing Address - Street 1:200 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3605
Mailing Address - Country:US
Mailing Address - Phone:601-849-9182
Mailing Address - Fax:601-849-5781
Practice Address - Street 1:200 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3605
Practice Address - Country:US
Practice Address - Phone:601-849-9182
Practice Address - Fax:601-849-5781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07135/11.1332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05080373Medicaid
MS05080373Medicaid