Provider Demographics
NPI:1083754816
Name:ICARERX, INC
Entity Type:Organization
Organization Name:ICARERX, INC
Other - Org Name:GAMMEL'S CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SHOFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-364-5100
Mailing Address - Street 1:909 UNITY RD
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-9444
Mailing Address - Country:US
Mailing Address - Phone:870-364-5100
Mailing Address - Fax:870-364-5120
Practice Address - Street 1:909 UNITY RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635
Practice Address - Country:US
Practice Address - Phone:870-364-5100
Practice Address - Fax:870-364-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR201463336C0003X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135016407Medicaid
AR5975870001Medicare NSC
AR5975870001Medicare NSC