Provider Demographics
NPI:1518962760
Name:FORT SMITH DIALYSIS SUPPLY COMPANY
Entity Type:Organization
Organization Name:FORT SMITH DIALYSIS SUPPLY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CNN
Authorized Official - Phone:479-709-6828
Mailing Address - Street 1:1506 DODSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-5128
Mailing Address - Country:US
Mailing Address - Phone:479-709-6828
Mailing Address - Fax:479-709-7453
Practice Address - Street 1:1506 DODSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5128
Practice Address - Country:US
Practice Address - Phone:479-709-6828
Practice Address - Fax:479-709-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3884140001Medicare ID - Type UnspecifiedPALMETTO GBA