Provider Demographics
NPI:1578542924
Name:ARCADIA VALLEY DRUG ACQUISITION CO
Entity Type:Organization
Organization Name:ARCADIA VALLEY DRUG ACQUISITION CO
Other - Org Name:USA DRUG OF ARCADIA VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:7645 E 63RD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1208
Mailing Address - Country:US
Mailing Address - Phone:918-858-4619
Mailing Address - Fax:918-592-4585
Practice Address - Street 1:605 N MAIN ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MO
Practice Address - Zip Code:63650-1006
Practice Address - Country:US
Practice Address - Phone:573-756-1024
Practice Address - Fax:573-747-0444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013885332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620054304Medicaid
MO5430570001Medicare NSC