MEDICARE: MEDIK CAROLINA MEDICAL SUPPLIES, INC.

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1942473723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIK CAROLINA MEDICAL SUPPLIES, INC.

Provider Business Mailing Address
First Line	:	5736 N TRYON ST
Second Line	:	SUITE 223B
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6850
Country	:	US
Telephone Number	:	704-790-3302
Fax Number	:

Provider Business Practice Location Address
First Line	:	5736 N TRYON ST
Second Line	:	SUITE 223B
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6850
Country	:	US
Telephone Number	:	704-790-3302
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LAFAYETTE BLACKMON
Credential	:
Telephone Number	:	704-790-3302

Provider Enumeration Date	:	04/11/2008
Last Update Date	:	04/27/2009

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