Healthcare Provider Details

I. General information

NPI: 1679129704
Provider Name (Legal Business Name): RED RIVER PHARMACY OF LITTLE ROCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S BOWMAN RD STE B
LITTLE ROCK AR
72211-4227
US

IV. Provider business mailing address

1550 MOORES LN
TEXARKANA TX
75503-4657
US

V. Phone/Fax

Practice location:
  • Phone: 501-907-8949
  • Fax: 501-907-6505
Mailing address:
  • Phone: 501-907-8949
  • Fax: 501-907-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: ROBIN BRULE
Title or Position: BUSINESS DIRECTOR
Credential:
Phone: 903-792-7435