Healthcare Provider Details

I. General information

NPI: 1962553404
Provider Name (Legal Business Name): TOMMYS REXALL DRUG COMPANY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 COURT SQ
DEWITT AR
72042-2057
US

IV. Provider business mailing address

220 COURT SQ
DEWITT AR
72042-2057
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-4221
  • Fax: 870-946-1181
Mailing address:
  • Phone: 870-946-4221
  • Fax: 870-946-1181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberAR14071
License Number StateAR

VIII. Authorized Official

Name: MR. TOMMY GLENN BLACK
Title or Position: PHARMACIST
Credential: P.D.
Phone: 870-946-4221