Provider Demographics
NPI:1134323421
Name:LILY MEDICAL EQUIPMENT SUPPLIER, INC.
Entity Type:Organization
Organization Name:LILY MEDICAL EQUIPMENT SUPPLIER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRUKTAWIT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-261-3729
Mailing Address - Street 1:2099 S ATLANTIC BLVD
Mailing Address - Street 2:UNIT O
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-6355
Mailing Address - Country:US
Mailing Address - Phone:323-261-3729
Mailing Address - Fax:323-261-3719
Practice Address - Street 1:2099 S ATLANTIC BLVD
Practice Address - Street 2:UNIT O
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-6355
Practice Address - Country:US
Practice Address - Phone:323-261-3729
Practice Address - Fax:323-261-3719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47296332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6031990001Medicare NSC