Provider Demographics
NPI:1083682363
Name:SPECIALTY MEDICAL SUPPLY OF ARKANSAS
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL SUPPLY OF ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-907-6490
Mailing Address - Street 1:806 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2920
Mailing Address - Country:US
Mailing Address - Phone:501-907-6490
Mailing Address - Fax:800-972-2925
Practice Address - Street 1:806 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2920
Practice Address - Country:US
Practice Address - Phone:501-907-6490
Practice Address - Fax:800-972-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3820332B00000X
AROS02062333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5370490001Medicare ID - Type Unspecified