Healthcare Provider Details

I. General information

NPI: 1013589514
Provider Name (Legal Business Name): MAINLINE PHARMACY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 JORDAN DR STE B
MONTICELLO AR
71655-5714
US

IV. Provider business mailing address

PO BOX 552
LAKE VILLAGE AR
71653-0552
US

V. Phone/Fax

Practice location:
  • Phone: 870-224-0650
  • Fax: 870-224-0652
Mailing address:
  • Phone: 870-265-2220
  • Fax: 870-265-3538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KHALIL L CROUSE
Title or Position: PRESIDENT
Credential:
Phone: 870-265-6604