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General NPI Number Information
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NPI Number | 1710022322
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Entity Type | Organization
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Legal Business Name | DIABETIC SUPPLY SOURCE, INC
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2805 MILLWOOD AVE
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City | COLUMBIA
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State | SC
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Zip | 29205-1298
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Country | US
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Telephone | 803-799-3505
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Fax | 803-256-1083
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Provider Business Mailing Address
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Address Line | PO BOX 25534
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City | COLUMBIA
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State | SC
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Zip | 29224-5534
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Country | US
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Telephone | 803-799-3505
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Fax | 803-256-1083
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOHN SHUFORD
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Credential |
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Telephone | 803-799-3505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number | 50-008619
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License Number State | SC
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