Healthcare Provider Details

I. General information

NPI: 1619246493
Provider Name (Legal Business Name): AMERICAN HOME PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: AMERICAN HOME PHARMACY

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 BONE ST
CLINTON AR
72031-6609
US

IV. Provider business mailing address

PO BOX 1060
CLINTON AR
72031-1060
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-4266
  • Fax: 501-745-5707
Mailing address:
  • Phone: 501-745-4266
  • Fax: 501-745-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR20639
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEREMY RIDDLE
Title or Position: PRESIDENT
Credential:
Phone: 501-745-4266