1093905721 NPI number — PHARMEDIC, INC

Table of content: (NPI 1093905721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093905721 NPI number — PHARMEDIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMEDIC, 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:
1093905721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HOT SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-525-3606
Provider Business Mailing Address Fax Number:
501-525-0628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4425 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-525-3606
Provider Business Practice Location Address Fax Number:
501-525-0628
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
501-525-3606

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  25090 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X , with the licence number: I930734 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 49255 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: AR0734 . This is a "EYEMED" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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