Healthcare Provider Details

I. General information

NPI: 1336256858
Provider Name (Legal Business Name): KILMICHAEL MEDICAL SUPPLIERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N FRONT STREET
WINONA MS
38967
US

IV. Provider business mailing address

PO BOX 185
KILMICHAEL MS
39747
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-1551
  • Fax: 662-283-2332
Mailing address:
  • Phone: 662-283-1551
  • Fax: 662-283-2332

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 Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH W WAKE
Title or Position: PRESIDENT
Credential:
Phone: 662-283-1551