Provider Demographics
NPI:1912278755
Name:MAK MEDICAL, LLC
Entity type:Organization
Organization Name:MAK MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLSAPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-336-7758
Mailing Address - Street 1:159 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1842
Mailing Address - Country:US
Mailing Address - Phone:229-336-7758
Mailing Address - Fax:229-336-5615
Practice Address - Street 1:159 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1842
Practice Address - Country:US
Practice Address - Phone:229-336-7758
Practice Address - Fax:229-336-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHHH000042332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA027448369BMedicaid
GA027448369BMedicaid