Provider Demographics
NPI:1033140082
Name:LILLY'S MEDICAL SUPPLY
Entity Type:Organization
Organization Name:LILLY'S MEDICAL SUPPLY
Other - Org Name:LILLY'S MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEVORK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETIKYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-836-3385
Mailing Address - Street 1:734 S BOULDER HWY # A
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7589
Mailing Address - Country:US
Mailing Address - Phone:702-836-3385
Mailing Address - Fax:702-856-3384
Practice Address - Street 1:734 S BOULDER HWY # A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7589
Practice Address - Country:US
Practice Address - Phone:702-836-3385
Practice Address - Fax:702-856-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5752100001Medicare NSC