Provider Demographics
NPI:1205475936
Name:DIVINE MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:DIVINE MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IFURE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-580-3740
Mailing Address - Street 1:3502 SATELLITE BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5820
Mailing Address - Country:US
Mailing Address - Phone:678-580-3740
Mailing Address - Fax:
Practice Address - Street 1:3502 SATELLITE BLVD STE 6
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5820
Practice Address - Country:US
Practice Address - Phone:678-580-3740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies