Provider Demographics
NPI:1215258652
Name:PREMIERE HEALTHCARE LLC
Entity type:Organization
Organization Name:PREMIERE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:870-931-9263
Mailing Address - Street 1:513 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1405
Mailing Address - Country:US
Mailing Address - Phone:573-996-3784
Mailing Address - Fax:
Practice Address - Street 1:513 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1405
Practice Address - Country:US
Practice Address - Phone:573-996-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6449440001Medicare NSC