Provider Demographics
NPI:1023022175
Name:GEORGIANA MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:GEORGIANA MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-376-0260
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:GEORGIANA
Mailing Address - State:AL
Mailing Address - Zip Code:36033-0132
Mailing Address - Country:US
Mailing Address - Phone:334-376-0260
Mailing Address - Fax:334-376-9609
Practice Address - Street 1:106 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GEORGIANA
Practice Address - State:AL
Practice Address - Zip Code:36033-4248
Practice Address - Country:US
Practice Address - Phone:334-376-0260
Practice Address - Fax:334-376-9609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL263332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1185510001Medicare NSC