Provider Demographics
NPI:1013589514
Name:MAINLINE PHARMACY SERVICES INC
Entity Type:Organization
Organization Name:MAINLINE PHARMACY SERVICES INC
Other - Org Name:CLINIC PHARMACY OF MONTICELLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-6604
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-0552
Mailing Address - Country:US
Mailing Address - Phone:870-265-2220
Mailing Address - Fax:870-265-3538
Practice Address - Street 1:535 JORDAN DR STE B
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5714
Practice Address - Country:US
Practice Address - Phone:870-224-0650
Practice Address - Fax:870-224-0652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy