Provider Demographics
NPI:1588080881
Name:ATLANTIC MEDICAL, LLC
Entity type:Organization
Organization Name:ATLANTIC MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-449-3200
Mailing Address - Street 1:1785 NONCONNAH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38132-2104
Mailing Address - Country:US
Mailing Address - Phone:662-449-3200
Mailing Address - Fax:888-891-3929
Practice Address - Street 1:1068 THOUSAND OAKS DR
Practice Address - Street 2:SUITE B
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-7742
Practice Address - Country:US
Practice Address - Phone:662-449-3200
Practice Address - Fax:888-891-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF11493332B00000X
MSF122163336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6722520001Medicare NSC