Healthcare Provider Details

I. General information

NPI: 1144559592
Provider Name (Legal Business Name): MEDIPHARM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W POLK AVE
WEST MEMPHIS AR
72301-4264
US

IV. Provider business mailing address

125 W POLK AVE
WEST MEMPHIS AR
72301-4264
US

V. Phone/Fax

Practice location:
  • Phone: 870-394-4209
  • Fax: 901-382-9966
Mailing address:
  • Phone: 870-394-4209
  • Fax: 901-382-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20617
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHIEMEZIE OTI
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 870-394-4209