Provider Demographics
NPI:1457772014
Name:MIRACLE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:MIRACLE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:601-428-4668
Mailing Address - Street 1:111 ELLISVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4519
Mailing Address - Country:US
Mailing Address - Phone:601-428-4668
Mailing Address - Fax:601-428-4668
Practice Address - Street 1:111 ELLISVILLE BLVD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4519
Practice Address - Country:US
Practice Address - Phone:601-428-4668
Practice Address - Fax:601-428-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-30
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies