Provider Demographics
NPI:1871694513
Name:DAVIS DRUG STORE INC
Entity type:Organization
Organization Name:DAVIS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-856-3080
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-0428
Mailing Address - Country:US
Mailing Address - Phone:870-856-3080
Mailing Address - Fax:870-856-4165
Practice Address - Street 1:1243 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9469
Practice Address - Country:US
Practice Address - Phone:870-856-3080
Practice Address - Fax:870-856-4165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR20337183500000X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146773407Medicaid