Provider Demographics
NPI:1366221293
Name:PKC MEDICAL SUPPLIES
Entity type:Organization
Organization Name:PKC MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:479-968-1777
Mailing Address - Street 1:915 W B ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3501
Mailing Address - Country:US
Mailing Address - Phone:479-968-1777
Mailing Address - Fax:479-967-1111
Practice Address - Street 1:915 W B ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3501
Practice Address - Country:US
Practice Address - Phone:479-968-1777
Practice Address - Fax:479-967-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies