Provider Demographics
NPI:1235570334
Name:KAVANAUGHRX LLC
Entity Type:Organization
Organization Name:KAVANAUGHRX LLC
Other - Org Name:KAVANAUGH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:501-664-3855
Mailing Address - Street 1:5200 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4609
Mailing Address - Country:US
Mailing Address - Phone:501-664-3844
Mailing Address - Fax:501-664-3744
Practice Address - Street 1:5200 KAVANAUGH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4609
Practice Address - Country:US
Practice Address - Phone:501-664-3844
Practice Address - Fax:501-664-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR041833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100024407Medicaid
2141594OtherPK