Provider Demographics
NPI:1801159157
Name:JACKSON DIABETIC SUPPLY
Entity type:Organization
Organization Name:JACKSON DIABETIC SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-563-1641
Mailing Address - Street 1:569 HIGHWAY 6 W
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-9519
Mailing Address - Country:US
Mailing Address - Phone:662-563-1641
Mailing Address - Fax:662-563-7304
Practice Address - Street 1:569 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-9519
Practice Address - Country:US
Practice Address - Phone:662-563-1641
Practice Address - Fax:662-563-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF11388332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies