Provider Demographics
NPI:1285683250
Name:BRENDA D POLSTON
Entity Type:Organization
Organization Name:BRENDA D POLSTON
Other - Org Name:THAT CERTAIN LOOK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:POLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-729-5490
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:300 VAN BUREN
Mailing Address - City:JUDSONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72081-0297
Mailing Address - Country:US
Mailing Address - Phone:501-729-5490
Mailing Address - Fax:501-729-1511
Practice Address - Street 1:300 VAN BUREN
Practice Address - Street 2:
Practice Address - City:JUDSONIA
Practice Address - State:AR
Practice Address - Zip Code:72081-0297
Practice Address - Country:US
Practice Address - Phone:501-729-5490
Practice Address - Fax:501-729-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440777Medicaid
AR141085716Medicaid
AR49701OtherBLUE CROSS BLUE SHIELD
AR49701OtherBLUE CROSS BLUE SHIELD
AR141085716Medicaid