Healthcare Provider Details

I. General information

NPI: 1467659144
Provider Name (Legal Business Name): GWINNETT SUPPLY COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
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: 770-962-1231
  • Fax: 770-513-2107
Mailing address:
  • Phone: 770-962-1231
  • Fax: 770-513-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. KIRTI K SHAH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 770-962-1231