Provider Demographics
NPI:1407844855
Name:COLEMAN BUTLER FT SMITH LLC
Entity Type:Organization
Organization Name:COLEMAN BUTLER FT SMITH LLC
Other - Org Name:COLEMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:479-783-5171
Mailing Address - Street 1:3610 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-6842
Mailing Address - Country:US
Mailing Address - Phone:479-783-5171
Mailing Address - Fax:479-783-0433
Practice Address - Street 1:3610 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-6842
Practice Address - Country:US
Practice Address - Phone:479-783-5171
Practice Address - Fax:479-783-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR109083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100228407Medicaid
OK100239790AMedicaid
1994117OtherPK
AR100228407Medicaid