Provider Demographics
NPI:1225023898
Name:PERSONAL MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:PERSONAL MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MC CHANCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-422-1271
Mailing Address - Street 1:373 W 1ST DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5207
Mailing Address - Country:US
Mailing Address - Phone:217-422-1271
Mailing Address - Fax:217-422-7066
Practice Address - Street 1:373 W 1ST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5207
Practice Address - Country:US
Practice Address - Phone:217-422-1271
Practice Address - Fax:217-422-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203-000093332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid