Provider Demographics
NPI:1679557342
Name:DIABETES SUPPLY OF CHARLOTTE
Entity type:Organization
Organization Name:DIABETES SUPPLY OF CHARLOTTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPARROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-948-9075
Mailing Address - Street 1:11601 ASBURY CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-4631
Mailing Address - Country:US
Mailing Address - Phone:704-948-9075
Mailing Address - Fax:704-948-1509
Practice Address - Street 1:11601 ASBURY CHAPEL RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4631
Practice Address - Country:US
Practice Address - Phone:704-948-9075
Practice Address - Fax:704-948-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
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
NC7701782Medicaid
MS0440545Medicaid
NC0421GOtherBCBS PROVIDER NUMBER
GA00713501AMedicaid
GA20543855OtherBCBS PROVIDER NUMBER
SCDM0863Medicaid
SCDM0863Medicaid