Provider Demographics
NPI:1912997172
Name:SOUTHERN DIABETIC SUPPLY COMPANY
Entity Type:Organization
Organization Name:SOUTHERN DIABETIC SUPPLY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:URQUIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-365-1100
Mailing Address - Street 1:14343 SE 34TH CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-2913
Mailing Address - Country:US
Mailing Address - Phone:901-365-1100
Mailing Address - Fax:
Practice Address - Street 1:14343 SE 34TH CT STE 1
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-2913
Practice Address - Country:US
Practice Address - Phone:901-365-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7415591OtherAETNA
MS04252570Medicaid
AR154596716Medicaid
OK200029690Medicaid
TN4084030OtherBLUECROSS BLUESHILD
TN1454404Medicaid
MS04252570Medicaid