Provider Demographics
NPI:1003943770
Name:JUNCTION CITY PHARMACY
Entity Type:Organization
Organization Name:JUNCTION CITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERPHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-924-4018
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71749-0780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 MAIN
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:AR
Practice Address - Zip Code:71749
Practice Address - Country:US
Practice Address - Phone:870-924-4018
Practice Address - Fax:870-924-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR181063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1222879Medicaid
AR100349407Medicaid