Healthcare Provider Details

I. General information

NPI: 1982997524
Provider Name (Legal Business Name): WYNNE MEDICAL PHARMACY OF CROSS COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 FALLS BLVD S
WYNNE AR
72396-3514
US

IV. Provider business mailing address

PO BOX 757
WYNNE AR
72396-0757
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-8531
  • Fax: 870-238-5982
Mailing address:
  • Phone: 870-238-8531
  • Fax: 870-238-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number06581
License Number StateAR

VIII. Authorized Official

Name: STEVE BRYANT
Title or Position: PRESIDENT
Credential:
Phone: 870-793-3999