Provider Demographics
NPI:1356229942
Name:MIMI MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:MIMI MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-702-3523
Mailing Address - Street 1:1905 W RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1502
Mailing Address - Country:US
Mailing Address - Phone:872-702-3523
Mailing Address - Fax:
Practice Address - Street 1:1905 W RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1502
Practice Address - Country:US
Practice Address - Phone:872-702-3523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies