Provider Demographics
NPI:1023177813
Name:PRO-MED MEDICAL SUPPLY
Entity type:Organization
Organization Name:PRO-MED MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SLADE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-353-2610
Mailing Address - Street 1:1313 N HILLS BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-3757
Mailing Address - Country:US
Mailing Address - Phone:501-353-2610
Mailing Address - Fax:501-353-2621
Practice Address - Street 1:1313 N HILLS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-3757
Practice Address - Country:US
Practice Address - Phone:501-353-2610
Practice Address - Fax:501-353-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7573332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49903OtherBLUE CROSS BLUE SHIELD
AR156282716Medicaid
AR5229750001Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID