MEDICARE: PRAIRIE MEDICAL SUPPLY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05827243	OTHER	IL	BCBS OF IL

General Provider Information

NPI Number	:	1790754711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	120 LEWIS PARK PLAZA
Second Line	:
City	:	MT ZION
State	:	IL
Zip	:	62549
Country	:	US
Telephone Number	:	217-864-0738
Fax Number	:	217-864-0743

Provider Business Practice Location Address
First Line	:	120 LEWIS PARK DR
Second Line	:
City	:	MT ZION
State	:	IL
Zip	:	62549-1202
Country	:	US
Telephone Number	:	217-864-0738
Fax Number	:	217-864-0743

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHARON S MANDLI
Credential	:
Telephone Number	:	217-454-0479

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	08/22/2020

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