Provider Demographics
NPI:1720055908
Name:TARGET MEDICAL, INC.
Entity Type:Organization
Organization Name:TARGET MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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 1:2158 HEYDE AV
Mailing Address - Street 2:STE 7
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38114-4840
Mailing Address - Country:US
Mailing Address - Phone:901-323-1304
Mailing Address - Fax:901-323-1275
Practice Address - Street 1:2158 HEYDE AV
Practice Address - Street 2:STE 7
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-4840
Practice Address - Country:US
Practice Address - Phone:901-323-1304
Practice Address - Fax:901-323-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001104332B00000X
MS04203 / 11.1332B00000X
ARMG01258332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN20077OtherTLC HME/DME PROVIDER
ARMG01258OtherBOARD OF PHARMACY - SUPPLIER OF MEDICAL EQUIPMENT, & MEDICAL GAS PERMIT
TN1452059Medicaid
TN3008232OtherTCS/BCBS HME/DME PROVIDR
TN=========OtherCIGNA HME/DME
IA=========OtherHOMELINK HME/DME
TN=========OtherAETNA
WI=========OtherHUMANA HME/DME
ARMG01258OtherBOARD OF PHARMACY - SUPPLIER OF MEDICAL EQUIPMENT, & MEDICAL GAS PERMIT
TN20077OtherTLC HME/DME PROVIDER
AR=========OtherARKANSAS MEDICAID
TN0754320001Medicare NSC