Provider Demographics
NPI:1497753461
Name:VILONIA DRUG INC
Entity Type:Organization
Organization Name:VILONIA DRUG INC
Other - Org Name:VILONIA DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBUCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:501-796-2116
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-0145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1155 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-9525
Practice Address - Country:US
Practice Address - Phone:501-796-2116
Practice Address - Fax:501-796-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
ARAR102493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100647407Medicaid
0410249OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0679160001Medicare NSC