Provider Demographics
NPI:1790754711
Name:PRAIRIE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:PRAIRIE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANDLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-454-0479
Mailing Address - Street 1:120 LEWIS PARK PLAZA
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549
Mailing Address - Country:US
Mailing Address - Phone:217-864-0738
Mailing Address - Fax:217-864-0743
Practice Address - Street 1:120 LEWIS PARK DR
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1202
Practice Address - Country:US
Practice Address - Phone:217-864-0738
Practice Address - Fax:217-864-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05827243OtherBCBS OF IL
IL05827243OtherBCBS OF IL
IL=========001Medicaid