Provider Demographics
NPI:1275548828
Name:EUDORA PHARMACY INC
Entity Type:Organization
Organization Name:EUDORA PHARMACY INC
Other - Org Name:EUDORA DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:870-355-4448
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-0552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EUDORA
Practice Address - State:AR
Practice Address - Zip Code:71640-3061
Practice Address - Country:US
Practice Address - Phone:870-355-4448
Practice Address - Fax:870-355-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR196893336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992912OtherPK
AR160503407Medicaid