Provider Demographics
NPI:1336256858
Name:KILMICHAEL MEDICAL SUPPLIERS INC
Entity type:Organization
Organization Name:KILMICHAEL MEDICAL SUPPLIERS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-283-1551
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:KILMICHAEL
Mailing Address - State:MS
Mailing Address - Zip Code:39747
Mailing Address - Country:US
Mailing Address - Phone:662-283-1551
Mailing Address - Fax:662-283-2332
Practice Address - Street 1:107 N FRONT STREET
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967
Practice Address - Country:US
Practice Address - Phone:662-283-1551
Practice Address - Fax:662-283-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440411Medicaid
MS00330316OtherPHARMACY
MS1138070001Medicare ID - Type Unspecified