1164563136 NPI number — MANES PHARMACY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164563136 NPI number — MANES PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANES PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164563136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 ALMA HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN BUREN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72956-5009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-474-5028
Provider Business Mailing Address Fax Number:
479-474-4792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 ALMA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN BUREN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72956-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-474-5028
Provider Business Practice Location Address Fax Number:
479-474-4792
Provider Enumeration Date:
02/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANES
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
479-474-5028

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  AR15009 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0415009 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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