Provider Demographics
NPI:1326015371
Name:CAEVERETT, INC
Entity Type:Organization
Organization Name:CAEVERETT, INC
Other - Org Name:CORNER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-291-0453
Mailing Address - Street 1:PO BOX 1370
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-1370
Mailing Address - Country:US
Mailing Address - Phone:870-368-7171
Mailing Address - Fax:870-368-5295
Practice Address - Street 1:830 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-7171
Practice Address - Fax:870-368-5295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR113663336C0003X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158762407Medicaid
1994142OtherPK
AR158762407Medicaid
AR159450716Medicaid