Healthcare Provider Details

I. General information

NPI: 1518962760
Provider Name (Legal Business Name): FORT SMITH DIALYSIS SUPPLY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 DODSON AVE
FORT SMITH AR
72901-5128
US

IV. Provider business mailing address

1506 DODSON AVE
FORT SMITH AR
72901-5128
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-6828
  • Fax: 479-709-7453
Mailing address:
  • Phone: 479-709-6828
  • Fax: 479-709-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAMELA SUE CLARK
Title or Position: DIRECTOR
Credential: RN,CNN
Phone: 479-709-6828