Provider Demographics
NPI:1932106663
Name:PROFESSIONAL MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:606-451-0216
Mailing Address - Street 1:342 BOGLE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2851
Mailing Address - Country:US
Mailing Address - Phone:606-451-0216
Mailing Address - Fax:606-451-1959
Practice Address - Street 1:342 BOGLE ST
Practice Address - Street 2:STE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2851
Practice Address - Country:US
Practice Address - Phone:606-451-0216
Practice Address - Fax:606-451-1959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY182153332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90013822Medicaid
3855710001Medicare NSC