Provider Demographics
NPI:1497100317
Name:GRACE-GARANTHE MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:GRACE-GARANTHE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZE OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:RANTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-441-9992
Mailing Address - Street 1:2400 WISTERIA DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2689
Mailing Address - Country:US
Mailing Address - Phone:770-441-9992
Mailing Address - Fax:
Practice Address - Street 1:2400 WISTERIA DR
Practice Address - Street 2:SUITE F
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2689
Practice Address - Country:US
Practice Address - Phone:770-441-9992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA298593332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA298593OtherHB