Provider Demographics
NPI:1578770582
Name:PORTLAND DRUG INC.
Entity Type:Organization
Organization Name:PORTLAND DRUG INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:ETHERIDGE
Authorized Official - Last Name:VEAZEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:870-737-2813
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:AR
Mailing Address - Zip Code:71663-0246
Mailing Address - Country:US
Mailing Address - Phone:870-737-2813
Mailing Address - Fax:
Practice Address - Street 1:105 HWY 165 SOUTH
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:AR
Practice Address - Zip Code:71663
Practice Address - Country:US
Practice Address - Phone:870-737-2813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04114293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0411429OtherNABP