Provider Demographics
NPI:1689691420
Name:LILLY MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:LILLY MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGOLLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-709-7475
Mailing Address - Street 1:334 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4216
Mailing Address - Country:US
Mailing Address - Phone:305-882-2704
Mailing Address - Fax:305-882-2706
Practice Address - Street 1:334 E 9TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4216
Practice Address - Country:US
Practice Address - Phone:305-882-2704
Practice Address - Fax:305-882-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022991100Medicaid
FL4004960001Medicare NSC