Provider Demographics
NPI:1902185788
Name:TARGET MEDICAL INC, MS
Entity Type:Organization
Organization Name:TARGET MEDICAL INC, MS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCKWAY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:901-323-1304
Mailing Address - Street 1:7065 AIRWAYS BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5873
Mailing Address - Country:US
Mailing Address - Phone:662-349-1394
Mailing Address - Fax:662-349-1394
Practice Address - Street 1:7065 AIRWAYS BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5873
Practice Address - Country:US
Practice Address - Phone:662-349-1394
Practice Address - Fax:662-349-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies