Healthcare Provider Details

I. General information

NPI: 1609531797
Provider Name (Legal Business Name): COMMUNITY CARE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 MARTIN LUTHER KING BLVD
MALVERN AR
72104-2006
US

IV. Provider business mailing address

1606 MARTIN LUTHER KING BLVD
MALVERN AR
72104-2006
US

V. Phone/Fax

Practice location:
  • Phone: 501-229-1446
  • Fax: 501-229-1397
Mailing address:
  • Phone: 501-229-1446
  • Fax: 501-229-1397

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: SHELYN DAVIS
Title or Position: PIC
Credential:
Phone: 501-844-1785