Provider Demographics
NPI:1861580987
Name:MEDICINE MAN MEDICAL SUPPLIES AND EQUIPMENT
Entity type:Organization
Organization Name:MEDICINE MAN MEDICAL SUPPLIES AND EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MISSROON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-6944
Mailing Address - Street 1:404 OLD TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5661
Mailing Address - Country:US
Mailing Address - Phone:843-871-6944
Mailing Address - Fax:843-871-9749
Practice Address - Street 1:404 OLD TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5661
Practice Address - Country:US
Practice Address - Phone:843-871-6944
Practice Address - Fax:843-871-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4815310001Medicare ID - Type UnspecifiedPROVIDER NUMBER