Healthcare Provider Details

I. General information

NPI: 1194822478
Provider Name (Legal Business Name): MEDICINE CHEST MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 E GARLAND ST
GRAND SALINE TX
75140-1984
US

IV. Provider business mailing address

411 MAIN ST
SULPHUR SPRINGS TX
75482-2762
US

V. Phone/Fax

Practice location:
  • Phone: 903-962-4251
  • Fax: 903-885-8734
Mailing address:
  • Phone: 903-885-0821
  • Fax: 903-885-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. DWAYNE MCCORMACK
Title or Position: PRESIDENT
Credential: RES THERAPIST
Phone: 903-962-4251