Provider Demographics
NPI:1780999318
Name:PREMIER MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:PREMIER MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-387-2488
Mailing Address - Street 1:1821 ROYAL AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5721
Mailing Address - Country:US
Mailing Address - Phone:318-387-2488
Mailing Address - Fax:318-387-2420
Practice Address - Street 1:1821 ROYAL AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5721
Practice Address - Country:US
Practice Address - Phone:318-387-2488
Practice Address - Fax:318-387-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2134396Medicaid
6502300001Medicare NSC