Provider Demographics
NPI:1518271139
Name:M & T VENTURES LLC
Entity Type:Organization
Organization Name:M & T VENTURES LLC
Other - Org Name:SAM ALEXANDER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-741-6511
Mailing Address - Street 1:127 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-4227
Mailing Address - Country:US
Mailing Address - Phone:870-741-6511
Mailing Address - Fax:870-365-0216
Practice Address - Street 1:127 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-4227
Practice Address - Country:US
Practice Address - Phone:870-741-6511
Practice Address - Fax:870-365-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ARAR145903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126195OtherPK
AR6475340001Medicare NSC