1366550626 NPI number — CITY DRUG STORE

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 1366550626 NPI number — CITY DRUG STORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY DRUG STORE
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:
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:
1366550626
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:
PO BOX 1190
Provider Second Line Business Mailing Address:
101 103 HIGHWAY 67 N
Provider Business Mailing Address City Name:
TUCKERMAN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-349-5161
Provider Business Mailing Address Fax Number:
870-349-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 103 HWY 67 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCKERMAN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-349-5161
Provider Business Practice Location Address Fax Number:
870-349-2863
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLAYTON
Authorized Official First Name:
OSCAR
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
870-349-5161

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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