Provider Demographics
NPI:1083600910
Name:REED DRUG STORE INC
Entity Type:Organization
Organization Name:REED DRUG STORE INC
Other - Org Name:DIABETES SHOPPE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-534-8351
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-4321
Mailing Address - Country:US
Mailing Address - Phone:870-534-8351
Mailing Address - Fax:870-850-6318
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-4321
Practice Address - Country:US
Practice Address - Phone:870-534-8351
Practice Address - Fax:870-850-6318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04D0983574 CLIA291U00000X
AR100103407332B00000X
AR140255716332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100-103-407Medicaid
AR140255716Medicaid
AR100-103-407Medicaid
AR1154600001Medicare NSC