Provider Demographics
NPI:1467457986
Name:PRIORITY MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:PRIORITY MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:601-319-1211
Mailing Address - Street 1:PO BOX 6370
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4123
Mailing Address - Country:US
Mailing Address - Phone:601-649-2212
Mailing Address - Fax:601-649-2110
Practice Address - Street 1:127 SOUTH 15TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4123
Practice Address - Country:US
Practice Address - Phone:601-649-2212
Practice Address - Fax:601-649-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS016041766332B00000X
MS06185/11.1332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03123717Medicaid
MS03123717Medicaid
MS03123717Medicaid