MEDICARE: PURDY MEDICAL WIGS & DME SUPPLIER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1770447799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURDY MEDICAL WIGS & DME SUPPLIER LLC

Provider Business Mailing Address
First Line	:	1942 W GRAY ST UNIT 1357
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-4816
Country	:	US
Telephone Number	:	678-439-8319
Fax Number	:	770-200-1620

Provider Business Practice Location Address
First Line	:	5801 ROCK SPRINGS RD
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-1504
Country	:	US
Telephone Number	:	678-439-8319
Fax Number	:	770-200-1620

Authorized Official
Title or Position	:	OWNER
Name	:	KAYLA ROSS
Credential	:
Telephone Number	:	678-439-8319

Provider Enumeration Date	:	12/13/2025
Last Update Date	:	12/13/2025

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