Healthcare Provider Details

I. General information

NPI: 1275960965
Provider Name (Legal Business Name): MALLARD MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E CHURCH ST
WARREN AR
71671-3454
US

IV. Provider business mailing address

801 E CHURCH ST
WARREN AR
71671-3454
US

V. Phone/Fax

Practice location:
  • Phone: 870-226-9501
  • Fax: 870-226-9500
Mailing address:
  • Phone: 870-226-9501
  • Fax: 870-226-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number14306
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY K WARDLAW
Title or Position: MEMBER
Credential:
Phone: 870-460-2814