MEDICARE: MAGNOLIA MEDICAL SUPPLY 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	225000000X	Orthotic Fitter
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1902565906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA MEDICAL SUPPLY LLC

Provider Business Mailing Address
First Line	:	1410 14TH ST STE B
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-4202
Country	:	US
Telephone Number	:	888-407-2823
Fax Number	:	888-435-9197

Provider Business Practice Location Address
First Line	:	1410 14TH ST STE B
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-4202
Country	:	US
Telephone Number	:	888-407-2823
Fax Number	:	888-435-9197

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID LOYD
Credential	:
Telephone Number	:	888-407-2823

Provider Enumeration Date	:	12/17/2021
Last Update Date	:	01/11/2022

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