Provider Demographics
NPI:1548328909
Name:LILLYS HOME MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:LILLYS HOME MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-255-0925
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-1148
Mailing Address - Country:US
Mailing Address - Phone:304-255-0925
Mailing Address - Fax:304-255-1005
Practice Address - Street 1:479 N VANCE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4158
Practice Address - Country:US
Practice Address - Phone:304-255-0925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0146663000Medicaid
WV0146663000Medicaid