Healthcare Provider Details

I. General information

NPI: 1023022175
Provider Name (Legal Business Name): GEORGIANA MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 CHURCH ST
GEORGIANA AL
36033-4248
US

IV. Provider business mailing address

PO BOX 132
GEORGIANA AL
36033-0132
US

V. Phone/Fax

Practice location:
  • Phone: 334-376-0260
  • Fax: 334-376-9609
Mailing address:
  • Phone: 334-376-0260
  • Fax: 334-376-9609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number263
License Number StateAL

VIII. Authorized Official

Name: JIMMY HARTIN
Title or Position: MANAGING EMPLOYEE
Credential:
Phone: 334-376-0260