Provider Demographics
NPI:1366879603
Name:PRESTIGE MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:PRESTIGE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-472-1102
Mailing Address - Street 1:2301 CONGRESS CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2557
Mailing Address - Country:US
Mailing Address - Phone:877-472-1102
Mailing Address - Fax:855-933-7002
Practice Address - Street 1:2301 CONGRESS CV
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2557
Practice Address - Country:US
Practice Address - Phone:877-472-1102
Practice Address - Fax:855-933-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR205025716Medicaid
7139350001Medicare NSC
7139350001Medicare NSC
CPED3606OtherABCOP
ATP14815OtherRESNA