Provider Demographics
NPI:1194837229
Name:MED SOUTH MEDICAL INC
Entity Type:Organization
Organization Name:MED SOUTH MEDICAL INC
Other - Org Name:FAMILY CHOICE NUTRITION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-753-9393
Mailing Address - Street 1:6415 WITT LN STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-2475
Mailing Address - Country:US
Mailing Address - Phone:501-753-9393
Mailing Address - Fax:501-753-9396
Practice Address - Street 1:6415 WITT LN STE B
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-2475
Practice Address - Country:US
Practice Address - Phone:501-753-9393
Practice Address - Fax:501-753-9396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31541360001332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163802716Medicaid
AR163802716Medicaid