Healthcare Provider Details

I. General information

NPI: 1023423423
Provider Name (Legal Business Name): MVP WARREN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MAIN ST
WARREN AR
71671-2714
US

IV. Provider business mailing address

PO BOX 552
LAKE VILLAGE AR
71653-0552
US

V. Phone/Fax

Practice location:
  • Phone: 870-226-3751
  • Fax: 870-226-3752
Mailing address:
  • Phone: 870-265-2220
  • Fax: 870-265-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR06454
License Number StateAR

VIII. Authorized Official

Name: NIKKI HOOD
Title or Position: CO-OWNER
Credential:
Phone: 870-265-2220