1396829438 NPI number — ELLISVILLE DRUG ACQUISITION CO.

Table of content: (NPI 1396829438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396829438 NPI number — ELLISVILLE DRUG ACQUISITION CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLISVILLE DRUG ACQUISITION CO.
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:
ELLISVILLE DRUG
Provider Other Organization Name Type Code:
3
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:
1396829438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
803 HIGHWAY 71 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71953-4367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-394-6363
Provider Business Mailing Address Fax Number:
479-394-1046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 HILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLISVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39437-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-477-3573
Provider Business Practice Location Address Fax Number:
601-477-3572
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEAVENY
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CONTRACTING MANAGER
Authorized Official Telephone Number:
612-227-7811

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  00140011 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2501218 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0330711 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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