Provider Demographics
NPI:1700078136
Name:TYSON MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:TYSON MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-284-9200
Mailing Address - Street 1:124 OLD MILL RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5362
Mailing Address - Country:US
Mailing Address - Phone:864-284-9200
Mailing Address - Fax:864-284-9209
Practice Address - Street 1:124 OLD MILL RD
Practice Address - Street 2:SUITE E
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5362
Practice Address - Country:US
Practice Address - Phone:864-284-9200
Practice Address - Fax:864-284-9209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2675Medicaid
SCDE2675Medicaid