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General NPI Number Information
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NPI Number | 1396219325
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Entity Type | Organization
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Legal Business Name | TRI-STATE MEDICAL SUPPLY LLC
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Dates
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Enumeration Date | 01/12/2019
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Last Update Date | 06/04/2020
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Provider Practice Location Address
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Address Line | 6392 HIGHWAY 51 N
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City | POPE
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State | MS
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Zip | 38658-2421
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Country | US
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Telephone | 662-703-0317
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Fax |
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Provider Business Mailing Address
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Address Line | 6392 HIGHWAY 51 N
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City | POPE
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State | MS
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Zip | 38658-2421
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Country | US
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Telephone | 662-267-3112
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MR. CLIFTON WADE GANT
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Credential | BS, RRT-NPS
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Telephone | 662-703-0317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number |
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License Number State |
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