Healthcare Provider Details

I. General information

NPI: 1649658287
Provider Name (Legal Business Name): DIVINE MEDICAL SUPPLIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BIRCH ST
RAEFORD NC
28376
US

IV. Provider business mailing address

310 BIRCH ST
RAEFORD NC
28376-3297
US

V. Phone/Fax

Practice location:
  • Phone: 910-904-2377
  • Fax: 910-904-2477
Mailing address:
  • Phone: 910-904-2377
  • Fax: 910-904-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number01700
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number01700
License Number StateNC

VIII. Authorized Official

Name: MRS. FLORINE FLEMING
Title or Position: OWNER
Credential: RN
Phone: 910-904-2377