Provider Demographics
NPI:1801823117
Name:GOODWILL MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:GOODWILL MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EQUERE
Authorized Official - Middle Name:EYO
Authorized Official - Last Name:UBOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-957-8144
Mailing Address - Street 1:903 PAVILION CT STE J
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6672
Mailing Address - Country:US
Mailing Address - Phone:770-957-8144
Mailing Address - Fax:770-957-8140
Practice Address - Street 1:903 PAVILION CT STE J
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6672
Practice Address - Country:US
Practice Address - Phone:770-957-8144
Practice Address - Fax:770-957-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001569332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
4962250001Medicare ID - Type Unspecified