Healthcare Provider Details

I. General information

NPI: 1124702592
Provider Name (Legal Business Name): DELTA DRUG OF DERMOTT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E PEDDICORD ST
DERMOTT AR
71638-2314
US

IV. Provider business mailing address

PO BOX 552
LAKE VILLAGE AR
71653-0552
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-5233
  • Fax: 870-538-5717
Mailing address:
  • Phone: 870-265-2220
  • Fax: 870-265-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CALLEY MCNEMAR
Title or Position: MANAGER
Credential:
Phone: 870-265-2220