Provider Demographics
NPI:1952014516
Name:SOURCE DIRECT MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:SOURCE DIRECT MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-472-8091
Mailing Address - Street 1:509 W 84TH DR STE C
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5694
Mailing Address - Country:US
Mailing Address - Phone:219-472-8091
Mailing Address - Fax:
Practice Address - Street 1:509 W 84TH DR STE C
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5694
Practice Address - Country:US
Practice Address - Phone:219-472-8091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies