MEDICARE: COLLIER DRUG STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy	AR14677	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1994731	OTHER		PK

General Provider Information

NPI Number	:	1427058593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLIER DRUG STORES INC

Provider Business Mailing Address
First Line	:	PO BOX 1085
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72702-1085
Country	:	US
Telephone Number	:	479-442-6262
Fax Number	:	479-521-9111

Provider Business Practice Location Address
First Line	:	197 E MAIN ST
Second Line	:
City	:	FARMINGTON
State	:	AR
Zip	:	72730-3077
Country	:	US
Telephone Number	:	479-267-4303
Fax Number	:	479-267-4311

Authorized Official
Title or Position	:	OWNER
Name	:	MEL COLLIER
Credential	:
Telephone Number	:	479-442-6262

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	02/20/2024

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