Provider Demographics
NPI:1326125063
Name:SUMMIT MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:SUMMIT MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-5426
Mailing Address - Street 1:PO BOX 2486
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-2486
Mailing Address - Country:US
Mailing Address - Phone:501-327-5426
Mailing Address - Fax:501-327-5881
Practice Address - Street 1:170 COMMERCE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7112
Practice Address - Country:US
Practice Address - Phone:501-327-5426
Practice Address - Fax:501-327-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG00806332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9061334Medicaid
MN129219OtherHEALTH PARTNERS
SCDM1270Medicaid
MN240067000Medicaid
MA432970700Medicaid
AR49980OtherAR BLUE CROSS BLUE SHIELD
MO626353304Medicaid
LA1034061Medicaid
AR5802460001Medicare NSC