Provider Demographics
NPI:1588783989
Name:ST. MARY'S MEDICAL SUPPLIES & EQUIPMENT CORP
Entity type:Organization
Organization Name:ST. MARY'S MEDICAL SUPPLIES & EQUIPMENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONJA
Authorized Official - Middle Name:SIMMONS
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-488-0207
Mailing Address - Street 1:212 E INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-5010
Mailing Address - Country:US
Mailing Address - Phone:704-633-4456
Mailing Address - Fax:704-633-4618
Practice Address - Street 1:212 E INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-5010
Practice Address - Country:US
Practice Address - Phone:704-633-4456
Practice Address - Fax:704-633-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704318Medicaid