=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124127220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MEDICAL STORE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 04/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 14TH ST
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-4145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-482-0099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5502
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39302-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-482-0099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DON LARKIN KENNEDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-703-9614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 050-05340-4
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------