Healthcare Provider Details

I. General information

NPI: 1538915459
Provider Name (Legal Business Name): WYNNE MEDICAL PHARMACY OF CROSS COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 FALLS BLVD S
WYNNE AR
72396-3514
US

IV. Provider business mailing address

718 FALLS BLVD S
WYNNE AR
72396-3514
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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. LESLIE A JOHNSON
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 870-238-8531