Provider Demographics
NPI:1669473427
Name:PHYSICIAN MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:PHYSICIAN MEDICAL SUPPLY INC
Other - Org Name:WWW.PHYSICIANMEDICAL.COM
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:419-945-2980
Mailing Address - Street 1:4229 MAJORNA DR
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44287-9652
Mailing Address - Country:US
Mailing Address - Phone:419-945-2980
Mailing Address - Fax:419-945-2981
Practice Address - Street 1:4229 MAJORNA DR
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:OH
Practice Address - Zip Code:44287-9652
Practice Address - Country:US
Practice Address - Phone:419-945-2980
Practice Address - Fax:419-945-2981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0909753Medicaid
OH0283650001Medicare NSC