Basic Information
| Provider Information | |||||||||
| NPI: | 1548204753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TECH MED SUPPLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390600636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019320673 | ||||||||
| FaxNumber: | 6014205299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 LAKELAND DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392328852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019320673 | ||||||||
| FaxNumber: | 6014205299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | GROGAN | ||||||||
| AuthorizedOfficialFirstName: | RONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6019320673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 06345/11.1 | MS | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 02971738 | 05 | MS | MEDICAID |