Provider Demographics
NPI:1407844418
Name:YELLVILLE DRUG STORE, INC.
Entity Type:Organization
Organization Name:YELLVILLE DRUG STORE, INC.
Other - Org Name:CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-449-4099
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:YELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72687-0730
Mailing Address - Country:US
Mailing Address - Phone:870-449-4099
Mailing Address - Fax:
Practice Address - Street 1:317 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:YELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72687-9924
Practice Address - Country:US
Practice Address - Phone:870-449-4099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR06644333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAR06644OtherPHARMACY LICENSE #
AR0406644OtherNCPDP ID#