Provider Demographics
NPI:1669532602
Name:TRIAD MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:TRIAD MEDICAL SUPPLY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROLLYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CRNI, OCN
Authorized Official - Phone:678-762-1520
Mailing Address - Street 1:360 WINKLER DR STE F
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-0764
Mailing Address - Country:US
Mailing Address - Phone:601-605-1699
Mailing Address - Fax:800-511-1137
Practice Address - Street 1:360 WINKLER DR STE F
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-0764
Practice Address - Country:US
Practice Address - Phone:601-605-1699
Practice Address - Fax:800-511-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06771-11.1332B00000X
MS06771/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07806820Medicaid
MS1030137OtherACM
MS611626100OtherACS
MS611626100OtherACS
MS07806820Medicaid
MS611626100OtherACS