Provider Demographics
NPI:1437157013
Name:PROFESSIONAL MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:RTS
Authorized Official - Phone:772-205-5408
Mailing Address - Street 1:101 N US HIGHWAY 1
Mailing Address - Street 2:SUITE 119
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4254
Mailing Address - Country:US
Mailing Address - Phone:772-205-5408
Mailing Address - Fax:
Practice Address - Street 1:101 N US HIGHWAY 1
Practice Address - Street 2:SUITE 119
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4254
Practice Address - Country:US
Practice Address - Phone:772-205-5408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1312539332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5336680001Medicare ID - Type UnspecifiedPROVIDER