Basic Information
| Provider Information | |||||||||
| NPI: | 1972662856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE DIABETIC STORE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7130 MOUNT ZION BLVD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704736811 | ||||||||
| FaxNumber: | 7704780238 | ||||||||
| Practice Location | |||||||||
| Address1: | 7130 MOUNT ZION BLVD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704736811 | ||||||||
| FaxNumber: | 7704780238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALVAREZ | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 7704607600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.