=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033134952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETIC SUPPLY & SUPPORT INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 04/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10365 HOOD RD S SUITE 103
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-448-3336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10365 HOOD RD S SUITE 103
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-448-3336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. HOLLY NICOLE WALDROP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-448-3336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH26639
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------