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General NPI Number Information
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NPI Number | 1851431399
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Entity Type | Organization
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Legal Business Name | PRESCRIPTION STORE OF FORDYCE INC
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 02/16/2012
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Provider Practice Location Address
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Address Line | 1115 W 4TH ST
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City | FORDYCE
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State | AR
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Zip | 71742-2001
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Country | US
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Telephone | 870-352-8631
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Fax | 870-352-8183
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Provider Business Mailing Address
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Address Line | 1115 W 4TH ST
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City | FORDYCE
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State | AR
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Zip | 71742-2001
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Country | US
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Telephone | 870-352-8631
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Fax | 870-352-8183
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Authorized Official
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Title or Position | PRESIDENT
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Name | JON DEAN
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Credential |
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Telephone | 870-352-8631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | AR14893
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License Number State | AR
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