Basic Information
| Provider Information | |||||||||
| NPI: | 1831287986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE OXYGEN STORE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 JOHN MADDOX DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062901330 | ||||||||
| FaxNumber: | 7062901332 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 JOHN MADDOX DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062901330 | ||||||||
| FaxNumber: | 7062901332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DUNLAP | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | WALTON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7062901330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 00953345A | 05 | GA | MEDICAID |