| Name: | Southern Express Medical Supply, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Dissolved |
| Date of registration: | 22 Oct 1997 (27 years ago) |
| Date of dissolution: | 19 Mar 2018 |
| Entity Number: | 000-190-937 |
| Register Number: | 000190937 |
| ZIP code: | 36033 |
| County: | Butler |
| Place of Formation: | Butler County |
| Registered Office Street Address: | 413 WEST RAILROAD AVEGEORGIANA, AL 36033 |
| Authorized Capital: | $1,000 |
Activities
SELL/RENT MEDICAL SUPPLIES AND EQUIPMENT
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1265431928 | 2005-07-15 | 2015-10-12 | PO BOX 710, GEORGIANA, AL, 36033, US | 125 CHURCH ST, SUITE B, GEORGIANA, AL, 36033, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 334-376-0003 |
| Fax | 3343765777 |
Authorized person
| Name | MR. MICHAEL BRUCE |
| Role | OWNER |
| Phone | 3343760003 |
Taxonomy
| Taxonomy Code | 332BP3500X - Parenteral & Enteral Nutrition Supplies (DME) |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS PROVIDER NUMBER |
| Number | 51077252 |
| State | AL |
| Issuer | HEALTH INS CORP OF AL |
| Number | 305157 |
| State | AL |
| Issuer | MEDICAID |
| Number | 000077252 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| SHIRLEY, JANICE D | Agent | 413 WEST RAILROAD AVENUE NORTHGEORGIANA, AL 36033 |
| Name | Role | Address |
|---|---|---|
| IVY CREEK HEALTHCARE LLC | Director | 16020 SW 80TH AVENUEMIAMI, FL 33157 |
| Name | Role | Address |
|---|---|---|
| SHIRLEY, JANICE D | Incorporator | 413 WEST RAILROAD AVENUE NORTHGEORGIANA, AL 36033 |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
