Provider Demographics
NPI:1477598795
Name:PEDIATRIC NUTRITION PROV OF AR
Entity Type:Organization
Organization Name:PEDIATRIC NUTRITION PROV OF AR
Other - Org Name:ACCESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:901-315-7337
Mailing Address - Street 1:920 EDISON AVE
Mailing Address - Street 2:STE 9
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 EDISON AVE
Practice Address - Street 2:STE 9
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4502
Practice Address - Country:US
Practice Address - Phone:501-315-7337
Practice Address - Fax:501-778-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR20528333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0422357OtherOTHER ID NUMBER-COMMERCIAL NUMBER