Healthcare Provider Details

I. General information

NPI: 1295752376
Provider Name (Legal Business Name): MARVELL CLINIC PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S MILL ST
MARVEL AR
72366-0217
US

IV. Provider business mailing address

PO BOX 217 406 S. MILL ST
MARVELL AR
72366-0217
US

V. Phone/Fax

Practice location:
  • Phone: 870-829-1044
  • Fax: 870-829-1067
Mailing address:
  • Phone: 870-829-1044
  • Fax: 870-829-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberAR20373
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberAR20373
License Number StateAR

VIII. Authorized Official

Name: MR. JOHN WILLIAM GRAY
Title or Position: OWNER PHARM
Credential: PHARMACIST
Phone: 870-829-1044