Provider Demographics
NPI:1518953132
Name:ALCO PHARMACY INC
Entity Type:Organization
Organization Name:ALCO PHARMACY INC
Other - Org Name:SAM ALEXANDER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
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:2005-09-20
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR145903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100163407Medicaid
AR119042716Medicaid
0414590OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR119042716Medicaid