Provider Demographics
NPI:1972925303
Name:RELIANT MEDICAL LLC
Entity Type:Organization
Organization Name:RELIANT MEDICAL LLC
Other - Org Name:RELIANT HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-322-8326
Mailing Address - Street 1:PO BOX 2293
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-2293
Mailing Address - Country:US
Mailing Address - Phone:877-354-2688
Mailing Address - Fax:318-354-0998
Practice Address - Street 1:3532 MANOR DR STE 4
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5629
Practice Address - Country:US
Practice Address - Phone:877-354-2688
Practice Address - Fax:318-322-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
MS12953/ 2.63336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143959OtherPK