Healthcare Provider Details

I. General information

NPI: 1275548828
Provider Name (Legal Business Name): EUDORA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MAIN ST
EUDORA AR
71640-3061
US

IV. Provider business mailing address

PO BOX 552
LAKE VILLAGE AR
71653-0552
US

V. Phone/Fax

Practice location:
  • Phone: 870-355-4448
  • Fax: 870-355-2444
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR19689
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KHALIL CROUSE
Title or Position: OWNER
Credential: RPH
Phone: 870-355-4448