Provider Demographics
NPI:1710774534
Name:LEGACY MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:LEGACY MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:WEATHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-214-3916
Mailing Address - Street 1:1616 GRAND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-3676
Mailing Address - Country:US
Mailing Address - Phone:847-942-1385
Mailing Address - Fax:
Practice Address - Street 1:1616 GRAND AVE STE 105
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-3676
Practice Address - Country:US
Practice Address - Phone:847-942-1385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-23
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies