Provider Demographics
NPI:1124127220
Name:THE MEDICAL STORE, INC.
Entity type:Organization
Organization Name:THE MEDICAL STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:LARKIN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-703-9614
Mailing Address - Street 1:PO BOX 5502
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5502
Mailing Address - Country:US
Mailing Address - Phone:601-482-0099
Mailing Address - Fax:
Practice Address - Street 1:1911 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4145
Practice Address - Country:US
Practice Address - Phone:601-482-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSH HEALTH SYSTEMS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS050-05340-4332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00040221Medicaid
MS000011075OtherBLUE CROSS BLUE SHIELD ID
AL008805990Medicaid
MS0229970001Medicare ID - Type UnspecifiedPROVIDER ID