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General NPI Number Information
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NPI Number | 1326015942
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Entity Type | Organization
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Legal Business Name | MED-CO DIABETIC SUPPLIES, INC.
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Dates
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Enumeration Date | 03/02/2006
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Last Update Date | 06/08/2009
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Provider Practice Location Address
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Address Line | 4964 UNIVERSITY PKWY SUITE-107
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City | WINSTON-SALEM
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State | NC
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Zip | 27106-2809
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Country | US
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Telephone | 336-661-1669
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Fax | 336-661-1678
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Provider Business Mailing Address
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Address Line | PO BOX 4143
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City | WINSTON-SALEM
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State | NC
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Zip | 27115-4143
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Country | US
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Telephone | 336-661-1669
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Fax | 336-661-1678
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Authorized Official
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Title or Position | OWNER / GENERAL MANAGER
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Name | MR. MICHAEL ALFONSO GILLIAM
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Credential |
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Telephone | 336-661-1669
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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 | 600424547
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License Number State | NC
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