Provider Demographics
NPI:1487661583
Name:PATS SUPER V DRUG STORE INC
Entity Type:Organization
Organization Name:PATS SUPER V DRUG STORE INC
Other - Org Name:SUPER V DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-972-6470
Mailing Address - Street 1:1000 E MATTHEWS AVE
Mailing Address - Street 2:STE A
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4307
Mailing Address - Country:US
Mailing Address - Phone:870-972-6470
Mailing Address - Fax:870-972-0710
Practice Address - Street 1:1000 E MATTHEWS AVE
Practice Address - Street 2:STE A
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4307
Practice Address - Country:US
Practice Address - Phone:870-972-6470
Practice Address - Fax:870-972-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
ARAR108213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128304716Medicaid
AR121246407Medicaid
1994112OtherPK
0942390001Medicare NSC