Provider Demographics
NPI:1275960965
Name:MALLARD MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:MALLARD MEDICAL SUPPLY LLC
Other - Org Name:MALLARD MEDICAL SUPPLY
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WARDLAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-460-2814
Mailing Address - Street 1:801 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-3454
Mailing Address - Country:US
Mailing Address - Phone:870-226-9501
Mailing Address - Fax:870-226-9500
Practice Address - Street 1:801 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-3454
Practice Address - Country:US
Practice Address - Phone:870-226-9501
Practice Address - Fax:870-226-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X, 332BX2000X
AR14306332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies