Provider Demographics
NPI:1255600698
Name:DONALSONVILLE TRI-STATE HOME MEDICAL LLC
Entity type:Organization
Organization Name:DONALSONVILLE TRI-STATE HOME MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH9642 REGISTERED P
Authorized Official - Phone:229-524-8911
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:801 N WILEY AVE
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-0157
Mailing Address - Country:US
Mailing Address - Phone:229-524-8911
Mailing Address - Fax:229-524-2300
Practice Address - Street 1:801 N WILEY AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1121
Practice Address - Country:US
Practice Address - Phone:229-524-8911
Practice Address - Fax:229-524-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000922237ABMedicaid
GA6720750001Medicare NSC