Provider Demographics
NPI:1396829438
Name:ELLISVILLE DRUG ACQUISITION CO.
Entity Type:Organization
Organization Name:ELLISVILLE DRUG ACQUISITION CO.
Other - Org Name:ELLISVILLE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:803 HIGHWAY 71 N
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4367
Mailing Address - Country:US
Mailing Address - Phone:479-394-6363
Mailing Address - Fax:479-394-1046
Practice Address - Street 1:915 HILL ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2419
Practice Address - Country:US
Practice Address - Phone:601-477-3573
Practice Address - Fax:601-477-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00140011333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2501218OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS0330711Medicaid
4450120001Medicare NSC