Healthcare Provider Details

I. General information

NPI: 1427821156
Provider Name (Legal Business Name): TRISTATE INFUSION CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 E MATTHEWS AVE STE C
JONESBORO AR
72401-4315
US

IV. Provider business mailing address

1107 E MATTHEWS AVE STE C
JONESBORO AR
72401-4315
US

V. Phone/Fax

Practice location:
  • Phone: 662-260-3366
  • Fax: 662-260-1568
Mailing address:
  • Phone: 662-260-3366
  • Fax: 662-260-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK RYAN MCFERRIN
Title or Position: OWNER
Credential:
Phone: 662-260-3366