Healthcare Provider Details

I. General information

NPI: 1437165057
Provider Name (Legal Business Name): KANAWHA MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14056 RICHMOND HIGHWAY
APPOMATTOX VA
24522
US

IV. Provider business mailing address

PO BOX 57
EVERGREEN VA
23939
US

V. Phone/Fax

Practice location:
  • Phone: 434-352-7671
  • Fax: 434-352-7673
Mailing address:
  • Phone: 434-352-7671
  • Fax: 434-352-7673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0206009331
License Number StateVA

VIII. Authorized Official

Name: MS. DYANE B PERGERSON
Title or Position: VICE PRESIDENT/OWNER
Credential:
Phone: 804-330-5743