Provider Demographics
NPI:1063936623
Name:SAFEWAY MEDICAL LLC
Entity type:Organization
Organization Name:SAFEWAY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOCO
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-674-2875
Mailing Address - Street 1:2330 SCENIC HWY S STE 303
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3115
Mailing Address - Country:US
Mailing Address - Phone:770-674-2875
Mailing Address - Fax:770-674-2876
Practice Address - Street 1:2330 SCENIC HWY S STE 303
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:770-674-2875
Practice Address - Fax:770-674-2876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies