Provider Demographics
NPI:1487640579
Name:MITCHELLS PARK STREET PHARMACY INC
Entity Type:Organization
Organization Name:MITCHELLS PARK STREET PHARMACY INC
Other - Org Name:MITCHELLS PARK STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-297-8107
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0569
Mailing Address - Country:US
Mailing Address - Phone:870-297-8107
Mailing Address - Fax:
Practice Address - Street 1:526 PARK ST
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519-9070
Practice Address - Country:US
Practice Address - Phone:870-297-8107
Practice Address - Fax:870-297-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ARAR202143336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100056407Medicaid
1994893OtherPK
0422210001Medicare NSC