Provider Demographics
NPI:1013188168
Name:DRUG STORE, INC
Entity Type:Organization
Organization Name:DRUG STORE, INC
Other - Org Name:THE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:501-223-2636
Mailing Address - Street 1:11121 N RODNEY PARHAM RD STE 42B
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4108
Mailing Address - Country:US
Mailing Address - Phone:501-223-2636
Mailing Address - Fax:501-224-5253
Practice Address - Street 1:11121 N RODNEY PARHAM RD STE 42B
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4108
Practice Address - Country:US
Practice Address - Phone:501-223-2636
Practice Address - Fax:501-224-5253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR175603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110981407Medicaid
AR110981407Medicaid