Provider Demographics
NPI:1003816174
Name:COLLIER DRUG STORES INC
Entity Type:Organization
Organization Name:COLLIER DRUG STORES INC
Other - Org Name:COLLIER DRUG-PRAIRIE GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-442-6262
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1085
Mailing Address - Country:US
Mailing Address - Phone:479-442-6262
Mailing Address - Fax:479-521-9111
Practice Address - Street 1:801 E DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-2737
Practice Address - Country:US
Practice Address - Phone:479-846-2195
Practice Address - Fax:479-846-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ARAR202823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145056407Medicaid
1994219OtherPK
1994219OtherPK