Provider Demographics
NPI:1215173422
Name:MARY D SMITH
Entity type:Organization
Organization Name:MARY D SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-572-2791
Mailing Address - Street 1:313 PLAZA
Mailing Address - Street 2:
Mailing Address - City:WEST HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72390-2453
Mailing Address - Country:US
Mailing Address - Phone:870-572-2792
Mailing Address - Fax:
Practice Address - Street 1:201 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4537
Practice Address - Country:US
Practice Address - Phone:870-364-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG00024332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143667716Medicaid
AR143667716Medicaid