Provider Demographics
NPI:1205119294
Name:OMNIMED MEDICAL SUPPLY AND EQUIPMENT L.L.C.
Entity type:Organization
Organization Name:OMNIMED MEDICAL SUPPLY AND EQUIPMENT L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGERS
Authorized Official - Middle Name:FULCHER
Authorized Official - Last Name:GOTIER
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:770-648-8622
Mailing Address - Street 1:927 COMMERCIAL ST NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-4537
Mailing Address - Country:US
Mailing Address - Phone:770-648-8622
Mailing Address - Fax:
Practice Address - Street 1:3113 EDINBURGH CT
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6863
Practice Address - Country:US
Practice Address - Phone:770-648-8622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies