Provider Demographics
NPI:1063474542
Name:PM SUPPLY LLC
Entity type:Organization
Organization Name:PM SUPPLY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:713-270-8183
Mailing Address - Street 1:8313 SOUTHWEST FWY
Mailing Address - Street 2:STE 223
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1612
Mailing Address - Country:US
Mailing Address - Phone:713-270-8183
Mailing Address - Fax:713-270-8175
Practice Address - Street 1:8313 SOUTHWEST FWY
Practice Address - Street 2:STE 223
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1612
Practice Address - Country:US
Practice Address - Phone:713-270-8183
Practice Address - Fax:713-270-8175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0086700332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148113702Medicaid
TX148113702Medicaid