Provider Demographics
NPI:1447640222
Name:HERRAKA LLC
Entity type:Organization
Organization Name:HERRAKA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRAKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-871-0992
Mailing Address - Street 1:3416 OLD GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5462
Mailing Address - Country:US
Mailing Address - Phone:352-871-0992
Mailing Address - Fax:479-242-2889
Practice Address - Street 1:3416 OLD GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:479-242-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193771001Medicaid
OK200449360AMedicaid
AR193771001Medicaid
5AQ08Medicare PIN