Healthcare Provider Details

I. General information

NPI: 1053881623
Provider Name (Legal Business Name): GWINNETT SUPPLY COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4315
US

IV. Provider business mailing address

605 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4315
US

V. Phone/Fax

Practice location:
  • Phone: 678-325-3331
  • Fax: 770-339-1859
Mailing address:
  • Phone: 678-325-3331
  • Fax: 770-339-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: PARMI SHAH
Title or Position: ADMINISTRATOR
Credential:
Phone: 678-469-9891