Provider Demographics
NPI:1043290299
Name:BRYANT HOLIFIELD & DAVIS PHARMACY
Entity type:Organization
Organization Name:BRYANT HOLIFIELD & DAVIS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/SECRETARY
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:870-523-9472
Mailing Address - Street 1:2200 MALCOLM AVENUE SUITE D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112
Mailing Address - Country:US
Mailing Address - Phone:870-523-9472
Mailing Address - Fax:870-523-9364
Practice Address - Street 1:2200 MALCOLM AVENUE SUITE D
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112
Practice Address - Country:US
Practice Address - Phone:870-523-9472
Practice Address - Fax:870-523-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-21
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR 20190333600000X
ARAR-201903336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138576407Medicaid
AR138576407Medicaid
AR5557240001Medicare NSC