Provider Demographics
NPI:1508903139
Name:WAYNE RAY HARVEY
Entity Type:Organization
Organization Name:WAYNE RAY HARVEY
Other - Org Name:PALACE DRUG
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-256-4317
Mailing Address - Street 1:PO BOX 1071
Mailing Address - Street 2:
Mailing Address - City:DES ARC
Mailing Address - State:AR
Mailing Address - Zip Code:72040-1071
Mailing Address - Country:US
Mailing Address - Phone:870-256-4317
Mailing Address - Fax:870-256-3387
Practice Address - Street 1:313 MAIN ST
Practice Address - Street 2:
Practice Address - City:DES ARC
Practice Address - State:AR
Practice Address - Zip Code:72040-1071
Practice Address - Country:US
Practice Address - Phone:870-256-4317
Practice Address - Fax:870-256-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04173703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120780407Medicaid
AR0417370OtherNABP
AR120780407Medicaid