Healthcare Provider Details

I. General information

NPI: 1801816616
Provider Name (Legal Business Name): NYAL DRUG STORE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 FRISCO ST
MARKED TREE AR
72365-2214
US

IV. Provider business mailing address

42 FRISCO ST
MARKED TREE AR
72365-2214
US

V. Phone/Fax

Practice location:
  • Phone: 870-358-2135
  • Fax: 870-358-4055
Mailing address:
  • Phone: 870-358-2135
  • Fax: 870-358-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6039
License Number StateAR

VIII. Authorized Official

Name: DR. RANDY LEE SHINABERY
Title or Position: OWNER
Credential: PD
Phone: 870-358-2135