Provider Demographics
NPI:1952417156
Name:UNIVERSAL MEDICAL SUPPLY CORP
Entity Type:Organization
Organization Name:UNIVERSAL MEDICAL SUPPLY CORP
Other - Org Name:UNIMED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-936-8487
Mailing Address - Street 1:1626 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-5909
Mailing Address - Country:US
Mailing Address - Phone:479-936-8487
Mailing Address - Fax:479-936-8222
Practice Address - Street 1:1626 S 8TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-5909
Practice Address - Country:US
Practice Address - Phone:479-936-8487
Practice Address - Fax:479-936-8222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSAL MEDICAL SUPPLY CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625882709Medicaid
AR056161OtherARKANSAS PHARMACY LICENSE
AR131093716Medicaid
AR1075240001Medicare NSC