Healthcare Provider Details

I. General information

NPI: 1184753899
Provider Name (Legal Business Name): PERRY COUNTY FOOD & DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 HOUSTON AVENUE
PERRYVILLE AR
72126
US

IV. Provider business mailing address

PO BOX 327 112 HOUSTON AVENUE
PERRYVILLE AR
72126
US

V. Phone/Fax

Practice location:
  • Phone: 501-889-3399
  • Fax: 501-889-2878
Mailing address:
  • Phone: 501-889-3399
  • Fax: 501-889-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0413132
License Number StateAR

VIII. Authorized Official

Name: MR. TRACY WALLACE SWAIM
Title or Position: PHARMACIST IN CHARGE
Credential: PD
Phone: 501-889-5826