Provider Demographics
NPI:1457401713
Name:GULF COAST SUPPLY LLC
Entity type:Organization
Organization Name:GULF COAST SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-645-2664
Mailing Address - Street 1:110 ZEIGLER CIRCLE EAST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608
Mailing Address - Country:US
Mailing Address - Phone:251-645-2664
Mailing Address - Fax:
Practice Address - Street 1:110 ZEIGLER CIRCLE EAST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:251-645-2664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL012077332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5255740001Medicare ID - Type Unspecified