Provider Demographics
NPI:1083625610
Name:SMACKOVER PHARMACY LLC
Entity Type:Organization
Organization Name:SMACKOVER PHARMACY LLC
Other - Org Name:SMACKOVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-814-3423
Mailing Address - Street 1:1402 PERSHING HWY
Mailing Address - Street 2:
Mailing Address - City:SMACKOVER
Mailing Address - State:AR
Mailing Address - Zip Code:71762-2300
Mailing Address - Country:US
Mailing Address - Phone:870-725-2220
Mailing Address - Fax:870-725-2040
Practice Address - Street 1:1402 PERSHING HWY
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-2300
Practice Address - Country:US
Practice Address - Phone:870-725-2220
Practice Address - Fax:870-725-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR205343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1989768OtherPK
AR160553407Medicaid