Healthcare Provider Details

I. General information

NPI: 1528058112
Provider Name (Legal Business Name): IMBODEN MEDICAL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WALNUT ST
IMBODEN AR
72434
US

IV. Provider business mailing address

203 WALNUT ST
IMBODEN AR
72434
US

V. Phone/Fax

Practice location:
  • Phone: 870-869-2046
  • Fax: 870-869-3302
Mailing address:
  • Phone: 870-869-2046
  • Fax: 870-869-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6091
License Number StateAR

VIII. Authorized Official

Name: MR. GEVAN D MURPHY
Title or Position: PHARMACIST MANAGER OWNER
Credential: PP
Phone: 870-869-2046