1972616126 NPI number — POLK PHARMACY MANAGEMENT, LLC

Table of content: (NPI 1972616126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972616126 NPI number — POLK PHARMACY MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POLK PHARMACY MANAGEMENT, LLC
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:
1972616126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8624 E WOODRUFF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERWOOD
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-681-5740
Provider Business Mailing Address Fax Number:
501-676-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 MADISON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARENDON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-747-3304
Provider Business Practice Location Address Fax Number:
870-747-5324
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ACHOR
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-681-5740

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  AR18271 , 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: 163890407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com