Provider Demographics
NPI:1205038585
Name:PROFESSIONAL DRIVERS MEDICAL DEPOTS
Entity Type:Organization
Organization Name:PROFESSIONAL DRIVERS MEDICAL DEPOTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-661-8929
Mailing Address - Street 1:3902 PETRO ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:615-661-8929
Mailing Address - Fax:615-661-8977
Practice Address - Street 1:3902 PETRO ROAD
Practice Address - Street 2:I-40, EXIT 280
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:615-661-8929
Practice Address - Fax:615-661-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center