MEDICARE: NYAL DRUG STORE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	6039	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0404575	OTHER	AR	NATIONAL PHARMACY NUMBER

General Provider Information

NPI Number	:	1801816616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NYAL DRUG STORE, INC

Provider Business Mailing Address
First Line	:	42 FRISCO ST
Second Line	:
City	:	MARKED TREE
State	:	AR
Zip	:	72365-2214
Country	:	US
Telephone Number	:	870-358-2135
Fax Number	:	870-358-4055

Provider Business Practice Location Address
First Line	:	42 FRISCO ST
Second Line	:
City	:	MARKED TREE
State	:	AR
Zip	:	72365-2214
Country	:	US
Telephone Number	:	870-358-2135
Fax Number	:	870-358-4055

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RANDY LEE SHINABERY
Credential	:	PD
Telephone Number	:	870-358-2135

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	08/06/2007

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Directions to “NYAL DRUG STORE, INC ” Practice Location

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