Provider Demographics
NPI:1225210735
Name:STATEWIDE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:STATEWIDE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-834-1887
Mailing Address - Street 1:PO BOX 7246
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72124
Mailing Address - Country:US
Mailing Address - Phone:501-834-1887
Mailing Address - Fax:
Practice Address - Street 1:6100 GETTY DR
Practice Address - Street 2:STE U
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-1635
Practice Address - Country:US
Practice Address - Phone:501-834-1887
Practice Address - Fax:501-834-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10724332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167086716Medicaid
AR6041080001Medicare NSC