Provider Demographics
NPI:1669772927
Name:MERIDIAN MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:MERIDIAN MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:CORLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-256-5700
Mailing Address - Street 1:1029 KEYSER AVE
Mailing Address - Street 2:SUITE M2
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6239
Mailing Address - Country:US
Mailing Address - Phone:318-238-7350
Mailing Address - Fax:318-238-7351
Practice Address - Street 1:1029 KEYSER AVE
Practice Address - Street 2:SUITE M2
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6239
Practice Address - Country:US
Practice Address - Phone:318-238-7350
Practice Address - Fax:318-238-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA35-0012400332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1356182Medicaid
LA1356182Medicaid