Provider Demographics
NPI:1427191154
Name:DELTA DRUG OF DERMOTT, INC
Entity Type:Organization
Organization Name:DELTA DRUG OF DERMOTT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, FAARM
Authorized Official - Phone:870-538-5510
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0348
Mailing Address - Country:US
Mailing Address - Phone:870-538-5510
Mailing Address - Fax:870-538-5717
Practice Address - Street 1:111 E PEDDICORD ST
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-2314
Practice Address - Country:US
Practice Address - Phone:870-538-5510
Practice Address - Fax:870-538-5717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR65032333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100262407Medicaid