Provider Demographics
NPI:1417908849
Name:JIMMMYS PHARMACY
Entity Type:Organization
Organization Name:JIMMMYS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESTIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:870-483-0400
Mailing Address - Street 1:1704 ST A WHY 69 BLVD
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1704 ST A WHY 69 BLVD
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472
Practice Address - Country:US
Practice Address - Phone:870-483-0400
Practice Address - Fax:870-483-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR205323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0422395OtherOTHER ID NUMBER-COMMERCIAL NUMBER