Healthcare Provider Details

I. General information

NPI: 1396219325
Provider Name (Legal Business Name): TRI-STATE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2019
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6392 HIGHWAY 51 N
POPE MS
38658-2421
US

IV. Provider business mailing address

6392 HIGHWAY 51 N
POPE MS
38658-2421
US

V. Phone/Fax

Practice location:
  • Phone: 662-703-0317
  • Fax:
Mailing address:
  • Phone: 662-267-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. CLIFTON WADE GANT
Title or Position: CO-OWNER
Credential: BS, RRT-NPS
Phone: 662-703-0317