Provider Demographics
NPI:1285649806
Name:M-C DRUG STORE LLC
Entity Type:Organization
Organization Name:M-C DRUG STORE LLC
Other - Org Name:M C DRUG STORE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-338-3414
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-0574
Mailing Address - Country:US
Mailing Address - Phone:870-338-3414
Mailing Address - Fax:870-338-3415
Practice Address - Street 1:533 PORTER ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-3217
Practice Address - Country:US
Practice Address - Phone:870-338-3414
Practice Address - Fax:870-338-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR03369333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992975OtherPK
AR160024407Medicaid