Provider Demographics
NPI:1063530996
Name:MEDICAL SUPPLY SUPERSTORE AT CHATHAM CROSSING
Entity type:Organization
Organization Name:MEDICAL SUPPLY SUPERSTORE AT CHATHAM CROSSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-220-0740
Mailing Address - Street 1:11312 US 15-501 NORTH
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11312 US 15-501 NORTH
Practice Address - Street 2:SUITE 306
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517
Practice Address - Country:US
Practice Address - Phone:919-960-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00481332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703100Medicaid
NC7703100Medicaid