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General NPI Number Information
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NPI Number | 1114014347
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Entity Type | Organization
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Legal Business Name | SOUTHERN MEDICAL SUPPLY
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Dates
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Enumeration Date | 10/09/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 91 CRYE LEIKE DR
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City | FORT OGLETHORPE
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State | GA
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Zip | 30742-4055
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Country | US
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Telephone | 706-861-7303
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Fax | 706-861-0201
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Provider Business Mailing Address
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Address Line | PO BOX 5513
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City | FORT OGLETHORPE
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State | GA
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Zip | 30742-0713
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Country | US
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Telephone | 706-861-7303
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Fax | 706-861-0201
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DONNA CARROLL
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Credential |
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Telephone | 706-861-7303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 957
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License Number State | GA
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