1457565400 NPI number — PROFESSIONAL PHARMACY

Table of content: (NPI 1457565400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457565400 NPI number — PROFESSIONAL PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PHARMACY
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:
CROWE DRUG CO
Provider Other Organization Name Type Code:
5
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:
1457565400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 N. MEDICAL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUTTGART
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-673-1741
Provider Business Mailing Address Fax Number:
870-673-1590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 N. MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUTTGART
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-673-1741
Provider Business Practice Location Address Fax Number:
870-673-1590
Provider Enumeration Date:
05/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
ZACHARY
Authorized Official Middle Name:
JUDSON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-673-1741

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100440407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".