Provider Demographics
NPI:1194186056
Name:ARKANSAS LIVER AND GASTROENTEROLOGY, PA
Entity Type:Organization
Organization Name:ARKANSAS LIVER AND GASTROENTEROLOGY, PA
Other - Org Name:SOUTHSIDE SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRAKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-242-2888
Mailing Address - Street 1:3416 OLD GREENWOOD RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5462
Mailing Address - Country:US
Mailing Address - Phone:479-242-2888
Mailing Address - Fax:479-242-2889
Practice Address - Street 1:3416 OLD GREENWOOD RD STE A
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:479-242-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR208293336C0002X, 3336C0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy