Healthcare Provider Details

I. General information

NPI: 1861580987
Provider Name (Legal Business Name): MEDICINE MAN MEDICAL SUPPLIES AND EQUIPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 OLD TROLLEY RD
SUMMERVILLE SC
29485-5661
US

IV. Provider business mailing address

404 OLD TROLLEY RD
SUMMERVILLE SC
29485-5661
US

V. Phone/Fax

Practice location:
  • Phone: 843-871-6944
  • Fax: 843-871-9749
Mailing address:
  • Phone: 843-871-6944
  • Fax: 843-871-9749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateSC

VIII. Authorized Official

Name: MICHELE A MISSROON
Title or Position: MANAGER/OWNER
Credential:
Phone: 843-871-6944