1073014866 NPI number — EAST END EXPRESS 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 1073014866 NPI number — EAST END EXPRESS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST END EXPRESS 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:
1073014866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21019 HIGHWAY 167, SUITE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENSLEY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-486-4100
Provider Business Mailing Address Fax Number:
501-486-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21019 HIGHWAY 167, SUITE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENSLEY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-486-4100
Provider Business Practice Location Address Fax Number:
501-486-4101
Provider Enumeration Date:
02/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GREENE
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
BRENNA
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
501-486-4100

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: AR20875 , 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: 2176226 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 225422407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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