Healthcare Provider Details

I. General information

NPI: 1922375559
Provider Name (Legal Business Name): MEDI SHOP PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HIGHWAY 71 S
MENA AR
71953-4638
US

IV. Provider business mailing address

204 HIGHWAY 71 S
MENA AR
71953-4638
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-3254
  • Fax: 479-394-0235
Mailing address:
  • Phone: 479-394-3254
  • Fax: 479-394-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR20383
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT GEYER
Title or Position: PHARMACIST
Credential: PHARM.D.
Phone: 479-394-7476